
Class 7?(X^/84 

Book :1]5^ 

CopiglitN? 



CQfKRIGlfr DEPOSIT. 



NOTES 



ON 



OBSTETRICS 



For the Junior and Senior Classes. 
Northwestern University Medical School. 



By 
JOSEPH B. De lee, 

Professor of Obstetrics 



1904 



PRESS OF 

Kenfield Publishing Co 

CHICAGO. 



LIBRARY of CONGRESS 
Two Copies Received ■ 

DEC 9 1904 

Copyngnt tntry 
«- XXc Noi 
PY B. 

.; J 



Copyright 1904, 
JosBPH B. Dk Lbe. 






PREFACE. 



The reader is requested to remember that this is not a treatise, 
but a volume of notes from the obstetric lectures of Dr. De^Lee, 
given to the Junior and Senior classes of the Northwestern Univer- 
sity Medical School. The essentials of the science and art are thor- 
oughly considered, and the book is intended for the class work of 
the students in the two years' course of instruction in midwifery. 
The author has sought to establish at the Northwestern, a School of 
Obstetrics whose principles and thought should guide the young 
practitioner in the first years of his practice or until he was capable, 
with safety to his patients, of thinking and acting for himself. This 
school of obstetric thought and practice is founded on the teachings 
of the late Dr. William Wright Jaggard, who occupied the chair of 
Obstetrics before the author ; upon the teachings of the leading 
accoucheurs of Vienna, Berlin and Paris, and upon his own experi- 
ence in dispensary, hospital and private practice. To accomplish 
the purpose the work of the whole teaching department, including 
the Chicago Lying-in Hospital and Dispensary, is intimately corre- 
lated, and developed in these Obstetric Notes. Uniformity of teach- 
ing and practice is thus assured and the student goes forth with a 
clear, rounded and definite knowledge of the art. A certain degree 
of dogmatism is unavoidable in attaining this end, but the student, 
becoming a practitioner, will soon find the flaws, if any, in these 
precepts, and will avoid them, while in the meantime his patients 
will not have been suffering from his lack of, or his desultory under- 
standing of, the art. 

The author invites correspondence on such subjects as his stu- 
dents find, in practice, to be at variance with his teachings. 

While these notes are to be used as a text-book, the student is 
urged to do as much .collateral reading in standard treatises on 
obstetrics as possible. A book written by the author, entitled 
"Obstetrics for Nurses," will give the student much information in 
the details of, actual obstetric practice. 

In these notes, smoothness of diction has, in many places, been 
sacrificed for brevity and terseness of expression. 

34 Washington St.,^ Joseph B. De Lei:. 

October ist, 1904. 



JUNIOR NOTES. 



NOTES ON OBSTETRICS. 



JUNIOR NOTES. 



At birth a girl and a boy baby are very much aHke. The boy 
weighs one-fourth to one-half of a pound more ; the head is a 
little larger, absolutely and relatively to the body. ^lore boys are 
born than girls, io6 to lOO, but more boys die during labor, because 
of their greater size, and more die during the first years of life. In 
the first year there is a change in the sexes and after the child walks 
one can easily tell the boy or girl. 

Sexually the boy and the girl are about alike up to the age of 
nine or ten, when they begin to change. This is most marked at the 
time of Puberty. 

Puberty may be defined as that period where the individual be- 
comes capable of reproduction. In females puberty begins between 
the thirteenth and fifteenth years ; in males the fourteenth and seven- 
teenth years. .The changes are more rapid and marked in the female, 
and are both physical and psychical. The pelvis enlarges, the limbs 
round out with fat, the breasts enlarge and become fuller, both by 
growth of gland and fat ; sometimes fine lines or striae appear on 
the breasts and buttocks, purplish at first, in four or five years white 
and silvery. The external genitals increase in size and become cov- 
ered with hair. Her general carriage changes. The thyroid en- 
larges, and in males the voice changes, while the sebaceous glands 
increase in size and activity. The mind changes in the three parts, — 
the will, the intellect, and the emotions. The will, especially during 
the change, becomes uncertain and the girl loses to a good extent 
her control over it. Hysterical manifestations are quite common. 
This is also true of the emotions. The inclination toward males 
increases and a sense of modesty develops. This transformation 
is the outward expression- of the changes in the internal organs of 
generation. The uterus is developing rapidly, the vagina lengthens 
and becomes rugous, the tubes enlarge, the ovaries take on especial 
activity, the ovaries develop and the Graafian Follicles become larg- 
er, 1. e., ovulation begins. 



10 NOTES ON OBSTETRICS— JUNIOR CLASS. 

Although the ability to reproduce begins after the beginning 
of puberty the girl is not yet fit to give birth to child. A child has 
been born to a girl of 9 years. Time set by Plato at twenty years. 
Wernich by study of the development of the fetus said that twenty- 
three is the best age for the first child. At this time also the pelvis 
is fully developed, the joints are not too firm, the coccyx can be 
pressed back, the genitals are soft and elastic. 

Early marriages are not to be recommended, often the children 
are weak and puny, but not always. The most important sign of 
the advent of puberty is the appearance of the Memes, or Menstrua- 
tion. This is a flow of blood of several days' duration, recurring 
every four weeks, attended by local symptoms referable to the gen- 
italia, and general symptoms. This again, is dependent upon, or co- 
related with changes going on in the ovaries, called Ovulation ; so 
that pubertv is marked by the inauguration of two new functions ; 
Menstruation and Ovulation, each of which we will now consider. 
Then fertilization or conception is to be considered, after which, the 
relation of the three to each other. 

Ovulation is that process by which an ovum ripens and is ex- 
truded from the ovary, that is, it is the maturation of the ovum or 
tgg, and expulsion of same from the ovary. 

OVULATION. 

The ovary is a densely fibrous little organ situated in the pelvis 
on the posterior surface of the broad ligament. It is 39 m.m. long, 
19 wide and 8 to 13 thick, and weighs 5 grms. Right is larger than 
the left and they can be felt in favorable cases bimanually. Right 
is less liable to disease. Shaped like a large lima bean, the flat ^dg^ 
being attached to the broad ligament by two layers of peritoneum, 
between which the vessels and nerves enter its substance. The outer 
edge is attached by one of the fimbriae of the Fallopian Tube to the 
tube. It is covered by a layer of flattened, columnar, lustreless epi- 
thelium, called the germ.inal epithelium, under which is the tough 
Tunica Albuginea. Beneath this are small unripe ova, while deeper 
down are larger ova in the process of ripening. These ova are sur- 
rounded by stroma, made up of elastic fibres, yellow and white, and 
unstriped muscular fibres, all three most abundant at the hilus. 

At the beginning of ovarian activity, the ovaries are smooth, but 
somewhat later they become puckered from numerous scars in their 
tissue. Tlie ova, of which in a new-born girl there are thirty or 
forty thousand, are contained in cavities called Graafian Follicles. 
The development of the ova and Graafian Follicles takes place during 
the intrauterine life of the girl and is as follows : Between the cylin- 
drical epithelial cells covering the ovary, lie somewhat spherical cells, 



NOTES ON OBSTETRICS— JUNIOR CLASS. 11 

so-called ''Primordial Ova." The epithelium covering the ovary dips 
into the stroma carrying the ova along. They are called by Walde- 
yer, the "Ovarian Tubes'' or ''Graafian Follicle bearing cord." The 
upper end of the tube becomes closed while the tube is divided by 
the stroma into roundish cavities, each containing one, or at most two 
ova. These are the Graafian Follicles and are lined by the relics 
of the epithelium v/hich dipped down from the surface and now 
form the so-called Membrana Granulosa. A fluid develops in the 
follicle and is called the liquor folliculi. At a certain point of the 
Membrana Granulosa, there is a heaping up of the cells, called the 
Discus Proligerus, to which th'e ovum is attached. The Graafian 
Follicle is surrounded by two layers, the Tunica Propria or vascu- 
losa, and the Tunica Fibrosa, both from the stroma of the ovary. 

The ova begins to be formed as early as the seventh month of 
fetal life and the full quota of ova that any female child has is 
probably made by the second year of its extrauterine life. Henle 
claimed one ovary held 36,000 ova. Waldeyer, both ovaries, 100,000 ; 
Sappey claimed there are 400,000. There are two layers of eggs, 
a cortical and a central ; the latter are larger and reach maturity 
sooner. 

The Graafian Follicle contains the liquor folliculi and the ovum 
which rests in the heaping of cells which is called the Discus Pro- 
ligerus. 

The function of the ovaries is to mature and discharge ova. 

Ovulation is that process by which an ovum ripens and is ex- 
truded from the ovary, that is, it is maturation of the ovum or tgg. 
They begin to ripen about the age of puberty, sometimes sooner. 

When an ovum begins to ripen, the Graafian Follicle containing 
it sinks toward the center of the ovary and the liquor folliculi in- 
creases. 

This Hquor folliculi is a viscid albuminoid, clear, alkaline fluid 
containing oil globules and a few granules. As the fluid increases 
the Graafian Follicle enlarges in the direction of the surface and the 
covering here becomes thinner. This point finally bursts and is 
called the stigma. The Graafian Follicle may be a centimeter to i^ 
centimenters large now. 

The ovum is a typical cell, and consists of 

1. Cells from the Discus Proligerus, or Cumulus Ovigerus, 

radiating and called corona radiata. 

2. A Zona Pellucida, the Vitelline membrane very thin and 

then the yelk or vitellus, a germinal vesicle, a germinal 

spot, and a paranucleolus. 
The Vitellus is made up of protoplasm, which is the active living 
part of the cell, and the deutoplasm, zvhich is to nourish the ovum 
and is a granular substance distributed through the protoplasm. It 



12 NOTES ON OBSTETRICS— JUNIOR CLASS. 

is minute in quantity and lasts only till the ovum gets nourishment- 
from the Fallopian Tube. Great similarity with the cell as you 
know it. 

The Zona Pellucida corresponds to the cell wall, the vitellus cor- 
responds to the cell contents, the germinal vesicle corresponds to 
the nucleus, the germinal spot corresponds to the nucleolus. 

During the process of ripening of the Graafian Follicle, changes 
occur in the ovum itself, which prepare it for the reception of the 
male element. The nucleus undergoes a process of unequal kar\'o- 
kinesis, approaches the surface of the vitellus and a part of it is ex- 
truded. This is called the first polar globule. Then after a period 
of quiescence the same process is repeated, extrusion of the second 
polar globule. The germinal vesicle and germinal spot are now 
called the female pronucleus. The ovum comes to resume nearly its 
original form, but can now be made fertile by the male element. This 
process of extrusion of the polar globule is a necessary process in 
man and the mammalia, but some low vegetable forms of life can do 
without it. 

There are tzi^o theories as to the cause of the extrusion of the 
polar globules. One that it is an excretion — the other, that this 
leaves the ovum in an incomplete state so that it needs a male ele- 
ment to make it fertile, and that the extrusion of same prevents 
p art hen o genesis . 

The Graafian Follicle has now reached its greatest size, the ovum 
is i/ 120 of an inch in diameter. Now the Graafian Follicle rup- 
tures, by the thin portion becoming necrotic, and the ovum, the discus 
proligerus and a little liquor folliculi are extruded. The ovum finds 
its way to the tube and awaits the male element so that it may be 
come fertilized by it and develop into a fetus. 

MENSTRUATION. 

This is also called the Period, Catamenia, ^Monthly Sickness, 
Cleansing, Flowers. It may be defined as a periodic flow of blood 
from the genitals, recurring every four weeks, accompanied by gen- 
eral symptoms of malaise, ner^-ous symptoms, etc., and local symp- 
toms of pelvic congestion. This phenomenon occurs during the nor- 
mal reproductive period of women, which begins with puberty, and 
continues up to forty-five years about. At this age, among other 
changes, the periods cease and the menopause, the Chmacteric, or 
the "change of life" takes place. 

The menstrual flow begins as a whitish discharge, but soon be- 
comes bloody and contains red and white blood corpuscles, degen- 
erated, ciliated and columnar epithelium, vaginal and uterine secre- 
tions and many micro-organisms, some of them septic. 



NOTES ON OBSTETRICS— JUNIOR CLASS. 13 

Menstruation is the most important of the outward changes which 
mark the advent of puberty, and the time of its occurrence is, of 
course, affected by the same conditions influencing the former. For 
example (i) Qimate, (2) Environment, (3) Race, (4) Heredity, 
i^5) Condition in Ufe, (6) Type of person. 

1. Cliniute, earUer in warm cUmate, e. g., Hindoos at twelve 

years. Remarkable that English w^omen in India 'men- 
struate much earlier than usual, and some menstruate in 
India, but not in England, or only during the summer. 

2. Raee. Jews menstruate early. Hungarians late. Rus- 

sians late. 

3. Environment. City bred girls early. Country girls late. 

due to the absence of sexual stimuli in the latter. 

4. Heredity. If mother menstruates early, children likely to 

do so. Can anticipate in the sisters. 

5. Condition in life. Poor factory girl who works hard, poor 

food, etc., late. Girl in luxury who reads novels, plays, 
dances, early. Chlorotic and tuberculous girls, late ; 
conservatism of nature. 

6. Type of Female. Blondes, especially red-haired girls, 

early. Brunettes late. Jews marked exception. 

Change in the uterus during menstruation, or what is the anatom- 
ical basis of menstruation ? 

This has been the subject of many years discussion and has not 
been decided as yet. We will consider the various theories advanced 
and later take one which is a good one to work on. 

All authors agree that the uterus is congested and that the mu- 
cous membrane is thickened and softened. Whereas it has a thick- 
ness of one to two mm. between two menstruations, during the 
period it reaches five to seven mm. That the glands enlarge, 
lengthen and establish freer secretion, all concede also; hut what 
part the ephitheliuni plays is the mooted point. 

Williams believed the whole endometrium was removed down 
to the muscularis and that it was reg-enerated from the remains of 
the uterine glands between the muscular fibres. 

Kundrat and Engelman believed that the upper layers of the 
miucous membrane were cast off, and a fatty degeneration occurred 
in them and the blood vessels, which' predisposed them to rupture, 
and therefore, the bloody flow. 

Leopold, of Dresden, believed that just the superficial -layers 
were removed by fatty necrosis and exfoliation. Best work is by 
Leopold. Moricke, who curetted the uteri of women during men- 
struation, says no epithelium is cast off at all, as the pieces he got 
out show^ed the mucous membrane to be intact. For our part, we 



14 NOTES ON OBSTETRICS— JUNIOR CLASS. 

will accept the following physical findings and hold to them till 
convinced otherwise. 

This description is from Ahlfeld. The endometrium is swollen 
and thick. The blood vessels and lymphatic vessels are dilated so 
that more fluid goes to the membrane than returns from it. The 
uterine glands are longer, the interglandular substance increased by 
added cells. The intercellular substance increases, especially in the 
upper layers of the mucous membrane, by exudation. The mucous 
membrane thus thickens and this thickened membrane is called the 
Decidua Menstriialis. When the congestion and swelling reach their 
highest mark, numerous minute hemorrhages occur in the decidua and 
under it between the glands. The epithelium is raised up by these 
hemorrhages and necrosis occurs, the piece is cast off and the blood 
is allowed to ooze out ; or comes directly from the capillaries. This 
blood mixes with the uterine and cervical mucus, loses its coagula- 
bility, takes a discolored aspect, (of a light maroon), and an odor 
which has been compared to marigold. 

The swelling of the mucous membrane gradually goes down, the 
epithelium which necrosed is cast off, regeneration takes place and 
the mucous membrane subsides into its quiescent condition. This 
takes about eight days. The changes are limited to the mucous 
membrane of the corpus uteri. This may be called a menstrual 
cycle, and happens every four weeks unless interrupted by pregnancy, 
lactation, or some other condition. 

What is the purpose of this periodical change in the endometrium ? 
Aveling called it ''Nest building/' and thus named the process which 
is now generally accepted, — that the surface is thus prepared for 
the reception of the fertilized Qgg, and is adapted for further growth 
of same. If the egg is not fertilized, the mucous membrane under- 
goes regressive changes to the normal. 

How do we explain these changes? Another field where opin- 
ions differ indefinitely. It is generally conceded that there exists 
a relation between menstruation and reproduction. The fact that 
they occur together, i. e., menstrual flow and the ability to reproduce, 
shows that something must exist between them, or they depend on 
the same cause. 

Bishoff finally concluded that menstruation depended on the ma- 
turation of the ovum. In other words, he said that a woman men- 
struates because certain changes go on in the ovary, which we term 
ovulation. 

Theories. Pfliiger said that the Graafian Follicle, by its grad- 
ual enlargement, exerted a compression of the nerves in the stroma 
of the ovary ; this irritation of nerves was at first mild but period- 
ically reached an acme of intensity which caused a congestion of the 
blood vessels of the pelvis. That this hastened the maturation of 



NOTES ON OBSTETRICS— JUNIOR CLASS. 15 

the ovum and the bursting of the Graafian Follicle on the one hand 
and on the other caused the changes in the endometrium which were 
described as the anatomical basis of menstruation, i. e., the swelling, 
exudates, etc. 

Arguments for this theory, of which the essential point is that 
ovulation determines menstruation and the analogy of menstruation 
to heat in animals. 

I. Since copulation during heat produces young, there must be 
ovulation at this time, and as thv animal has a sort of menstruation 
during the heat, i. e., the genitals r^ave bloody mucus, the compari- 
son seems good. 

II. Could feel the enlarged ovaries bi manually or could feel them 
in a hernia of the tube. Demonstrated the enlargement before each 
menstruation and ovulation. 

III. Anatomically could demonstrate scars of ruptured follicles 
in the ovary post-mortem and during laparotomy. Hyrtl, case of 
a girl who died after eight menstruations. Four scars in each ovary. 

IV. Removal of the ovaries by operation and the cessation of 
ovulation with cessation of menses. 

V. Cases of congenital absence of the ovaries. No menses. Ar- 
guments against this theory. 

I. Leopold, at laparotomies determined that ovulation may oc- 
cur between the periods at any time. Atypical and in diseased ova- 
ries. 

II. Ovulation must occur before menstruation begins, in some 
women, as the cases of child-birth before puberty show. "Fruit be- 
fore Flowers." — De la Motte. 

III. Some animals, ovulation occurs long before the heat. 

IV. Copulation seems to have some influence on ovulation as 
proved by: 

a. Certain tortoises cohabit two years before eggs are fertile. 

b. Copulation increases congestion in the pelvis and may hast- 

en the bursting of a Graafian Follicle. Example of 
rabbit. 

c. Puberty occurs earlier in the countries where child mar- 

riages are allowed. 

Pfliiger more recently has modified his theory to this extent, 
that he says the monthly ovulation is the typical one, and ovulation 
between periods is atypical. There is color lent to this view when 
one considers that the rnaterial on which Leopold based his views, 
were ovaries extirpated for disease. 

Halban has sought to prove that the internal secretion of the 
ovaries causes the menstruation. In monkeys, he transplanted ova- 
ries to distant parts of the body and the functions continued. Then 
removed them and the menses disappeared. 



16 NOTES ON OBSTETRICS— JUNIOR CLASS. 

Second Theory that menstruation causes ovulation. Untenable 
because : 

1. Ovulation precedes menstruation. 

2. Women can conceive without ever having menstruated. 

3. Ovulation occurs during the amenorrhea of lactation and 

rarely during pregnancy. 

Very recently Leopold and IMironoff have suspected that the 
periodicity of ovulation may be dependent on menstruation; i. e., 
that ovulation goes on all the time, but that every month a Graafian 
follicle ripens as the result of menstruation. Must now explain the 
periodicity of menses. There have been determined in women, as 
well as men, certain waves of functions; periodic increase of urea 
excretion, periodic accessions of nerve force, of spirits, of the in- 
tensity of living. On this investigation we may find the cause of 
ovulation and menstruation. 

Third Theory, by Auvard, that both are dependent on a third 
cause. 

1. This makes us suppose something that we know nothing 

about unless this periodicity before mentioned. 

2. Again, we ought to have menstruation after extirpation of 

the ovaries as the cause must act on both. 

Now, after having given types of the various hypotheses on this 
complicated subject, I will formulate a theory which seems most 
plausible to me and which is accepted by the majority of authors, 
which is a good working theory and will do service till a better one 
is proven. 

By the gradual development of the Graafian Follicle, a nervous 
impulse is transmitted to the blood vessels of the genitals, which 
causes pelvic congestion. This causes the more rapid maturation 
of the Graafian Follicle. At the height of the congestion the Graafian 
Follicle ruptures. The same congestion causes the uterine mucosa 
to undergo the changes we learned under menstruation. The mucous 
membrane is thus prepared for the reception of the ovum, if it be 
fertilized. If the male element has access to the avum the latter 
locates itself on the mucosa so prepared (or, as it is called, the 
Decidua Menstrualis). The egg develops into the fetus, the Decidua 
Alenstrualis being changed into a Decidua Graviditatis. If the 
ovum is not fertilized by a male element, it passes out with the 
menstrual flow unnoticed and the mucosa goes back to its original 
condition before menstruation. V/e must admit that ovulation mo-y 
occur at any time, hut must regard ovulation at the time of men- 
struation as the more common, w^'He inter-nienstrual ovulation, or 
that caused by copulation, is uncommon. 

Formerly many theories were held as to the reason for the 
phenomenon of menstruation. 



NOTES ON OBSTETRICS— JUNIOR CLASS. 17 

1. Oldest was probably that of a general plethora. A woman 

was endowed with greater blood-making powers, as she 
must nourish the fetus also. If she remained sterile, 
there was no need for this extra blood and it was thus 
gotten rid of. While by no means accepting this theory, 
it is interesting to note that in poorly nourished girls, 
or those of a tuberculous type, nature withholds the 
menses for no other reason, obviously, than to save the 
organism this useless waste of blood. 

2. A theory little less old, that of a purification. Even yet, 

by some races, women, while menstruating, are regarded 
unclean. The substances were supposed to be poisons, 
which were passed in the period. Recently a Southern 
writer said that cases of the retention of the menses 
could result in headache, neuralgia and rheumatic pains, 
even epilepsy. In Germany, the term "Monatliche 
Reinigung" — Monthly Cleansing, is still used. 

3. Pfliiger said the hemorrhage prepared the mucous mem- 

brane of the uterus for the reception of the egg. Avel- 
ing modified this, and it is so generally accepted ; he 
called it "Nest building." 

4. Power said : "A woman menstruates because she does not 

conceive," which goes nicely together with the latest 
view, for if the nest is not needed, the mucous mem- 
brane undergoes regressive changes under the clinical 
picture of menstruation. 
Do the tubes menstruate ? Reasons for believing they do : 

1. Hematosalpinx. 

2. Tubes fastened to the abdominal wall have regular hemor- 

rhages. 
Objections are: 

I. That the tubes in both cases are pathological — and again, 
that in either case the blood may have regurgitated from 
the uterus. At our present state of knowledge, can 
neither affirm nor deny tubal menstruation. 

CLINICAL ASPECTS OF MENSTRUATION. 

From the time of its onset, menstruation recurs about every four 
weeks till the menopause. During pregnancy the flow ceases. 
There are some cases of. menstruation during pregnancy on rec- 
ord, but they are rare and seldom bear investigation. 

During lactation the flow often ceases. Thirty per cent, of 
cases no menses for six months. Carl Braun found seventy per 
cent, where it recurred after six weeks. First menses usually pro- 
fuse, and sometimes alarms patient. Sometimes after app.earing 



18 NOTES ON OBSTETRICS— JUNIOR CLASS. 

a few times, it will remain absent for a year or six months. This 
is not abnormal if Syphilis, Chlorosis and Tuberculosis can be elim- 
inated. 

A. Symptoms. At the onset of a period, the woman has symp- 
toms referable to the genitalia, and general symptoms, called the 
Menstrual Molimina. There is often headache, (throbbing) ma- 
laise, temperature a degree higher, pulse higher and more variable, 
a feeling of lassitude. There may be neuralgia in various parts of 
the body, especially the face, pain in the breasts and some secretion 
of a watery milk, perhaps breasts somewhat swollen. Chilliness may 
occur, dark circles form around the eyes and flashes of heat occur, 
face and eyes perhaps a little flushed and some irritation of the 
bladder noticeable. Perhaps diarrhea. Sexual desire usually in- 
creased. Remarkable that mild attacks of tonsillitis are common 
during that period. The thyroid often enlarges and sometimes this 
remains more or less permanent. Amount of urea decreased, while 
CO^ increased. Emunctories generally more active and patient likely 
to take cold at this period. There may be light attacks of hysteria, 
together with an increased nervous sensibility. Sometimes an erup- 
tion on the skin, resembling Urticaria. Locally, External organs 
a little darker in color and swollen, which causes a feeling of bear- 
ing down or as if the genitals were open, backache, an increased 
sensibility in the iliac fossae (ovaries). Perhaps some tympany. The 
genitals are congested, uterus enlarges, a somewhat temporary hyper- 
trophy and the organ pours out an increased discharge. Cervix 
softened and somewhat open. 

B. Character of the How. At first, muco-serous, then a tinge 
of blood, later pure blood of a dark red, maroon color, which does 
not coagulate. In chlorotic girls is very watery, or the flow may be 
entirely colorless. It is alkaline and smells like marigold, some- 
times has a very bad odor; does not coagulate because mixed with 
the secretions, or the blood is defibrinated by its passage. If the 
flow is profuse, may be clotted, which is always pathological. Quan- 
tity is four to six ounces ; woman uses about four napkins daily. 
Counting the number of napkins used is a good way to determine 
if menorrhagia. 

C. Duration . Flow lasts from four to seven days. Anglo- 
Saxons average three to five; French, five to seven days. At be- 
ginning of puberty, flow is moderate; after married life, becomes 
more prpfuse, first, because of irritation, and second, because of the 
endometritis which so frequently develops, either from childbirth or 
gonorrhea. Toward the menopause the flow grows smaller in 
amount, increased by sexual excitement, novels, good food. Said 
that warm climate increases the flow, but this is doubtful. Brunettes 
said to flow more than blondes, but often blondes flow a great deal. 
Generally admitted, especially by Dr. Hodge, that each woman is 



NOTES ON OBSTETRICS—JUNIOR CLASS. 19 

a case for herself and that the best evidence of a normal flow is the 
effect on the woman ; if she is healthy, the flow is all right. 

D. Periodicity. Almost all women, at least seventy-one per 
cent, menstruate every twenty-eight days, and the majority during 
the new moon. A day earlier or later is of no importance. There 
are several types, as a twenty-eight-day type (71%), a twenty-one- 
day type (2%), a thirty-day type (14%), a twenty-seven-day type 
(1%), though some women flow every six weeks and are healthy. 

The Menopause^ — Change of Life, — Climacteric, — ^takes place 
from the fortieth to the fiftieth years. Cases where menses continued 
and even conception has taken place, are recorded in forty-eighth, 
fifty-second, even sixty-second year (Kennedy), though these are 
exceptions. 

From 35 to 40 years 12% cases cease to menstruate. 

P>om 40 to 45 years 25% cases cease to menstruate. 

From 45 to 50 years 50% cases cease to menstruate. 

From 50 to 55 years 12% cases cease to menstruate. 

Menopause occurs earlier in sterile women, earlier in cold than 
warm climates, earlier in the poor than in the rich, in black than in 
white women ; so that it has the same variability as in the beginning 
of puberty. The periods may cease and return later, ( Charpentier- 
Parvin). Case of woman ceased at forty-eight, began at sixty and 
continued two years normally. These cases are suspicious of dis- 
ease ; cancer, fibroid. If early puberty, menopause early ; late 
puberty, late menopause; menopause is often heralded by irregu- 
larities in the flow. Often it stops and does not reappear ; some- 
times a discharge of mucus or serum replaces it; sometimes there 
may be nervous symptoms, especially flushings of the face and body, 
which occur daily, weekly, or every month or year. Nervous symp- 
toms usual in nulliparae. Hysterical manifestations may occur. 
Sometimes patients complain that between the menstrual periods 
they have symptoms of a period, but there is no flow of blood. This, 
which Fasbender studied, is described by Martin as ''mittelschmerz," 
and means pain between the periods. Often has to do with diseased 
genitals and the symptoms of the Molimina are sometimes so severe 
as to require treatment. 

HYGIENE OF MENSTRUATION. 

A young girl, developing into womanhood, goes through a very 
important change and is liable to diseases which may influence her 
whole life. The nervous system, in addition to the genitals, is grow- 
ing rapidly and it is essential that she be given proper food, etc., 
for growth; she is more liable to headache and all sorts of nervous 
manifestations. Anemia, especially, if the congenital narrowness 



20 NOTES ON OBSTETRICS— JUNIOR CLASS. 

of the aorta described by X'irchow as a cause of chlorosis exists, is 
likely to develop now. 

Very recently a foreign author has advanced the idea that 
chlorosis is an infectious disease. A'ery little proof. She needs 
all her blood for her animal organism and, therefore, ought not to 
work hard at anything else, especialh school study. It is better 
that the girl go to bed with her first menses. 

How often we see the girl shoot up into the woman, but get thin, 
j..ale, yellow, subject to headaches, eye strain, indigestion, urticaria, 
etc. Take them out of school, send to the country, and the change 
is something wonderful. IMothers should instruct the girl as to 
what is coming, as she may try to conceal the flow, or may be 
greatly alarmed by its appearance. There may be some premonitory 
signs, as a discharge of mucus several months before blood comes. 
Pain and drawing in the lower abdomen. 

During an ordinary menstrual period, women had better lie on 
sofa, still better in bed. Often, especially in the poorer classes, they 
do neither, but work around as usual. She should not go to a ball 
or party where she can dance and get cold. No active exercise, 
e. g., horse-riding, skating, tennis. Should wear warmer clothing. 
Avoid cold bathing, especially sea bathing. Fatal, cases after the 
latter. Girls do these things to conceal their condition, but they are 
really "unwell." Rest is the best remedy for the condition brought 
about by the neglect of these rules, as Dysmenorrhea, Amenorrhea, 
Menorrhagia. Great good accomplished by adherence to above 
rules. Use medicine very sparingly. 

Patient should avoid cohabitation before, during, and for a few 
days after the period. It may cause a severe hemorrhage, by in- 
creasing pelvic congestion, and perhaps regurgitation of the blood 
along the Fallopian Tube. Further, the menstrual blood may cause 
a urethritis in the male. In the Mosaic Law, cohabitation is for- 
bidden, the woman being unclean. 

A few words about vicarious menstruation. This is a periodic 
discharge of blood from some surface other than the uterus, which 
discharge is to represent the monthly flow, such flow being absent 
from the uterus. 

Three (3) conditions must be fulfilled by the flow: 

1. The normal flow must be absent during the period : 

2. The organ from which the blood comes must be normal : 

3. The periodicity must be absolute. 

Hemorrhages have been described as coming from the nose, 
mouth, lungs, stomach, breasts, piles, or an ulcer. Dr. Jaggard 
says he has seen no authentic case of vicarious menstruation, and 
there was always some other cause for the bleeding. The author 
saw a case of irregular bleeding from an apparently healthy nipple. 



NOTES OX OBSTETRICS— JUNIOR CLASS. 21 

menses absent. Playfair says it occurs in young, delicate, mobile, 
nervous women, and it may be limited to puberty, or perhaps the 
whole sexual life. 

Precocious Menstruation is that which occurs before the usual 
time of puberty. It is due, according to Raciborski, to a premature 
development of the "genital sense." And Raciborski says the genital 
sense is that power which causes the development of the Graafian 
follicles. 

Parvin mentions a case where menses began at 3^ years. Some- 
times there is some disease underlying the phenomenon, though often 
the girls were healthy. Not seldom there is a sort of pseudo- 
menstruation in girl babies in the first week of life. There is a 
bloody mucoid discharge from the vagina, which lasts twenty-four 
to seventy-two hours. The general health of the infant is not dis- 
turbed, and the discharge does not recur. 

Precocious births have occurred. Instances on record where a 
girl eight years old had a child. 

CONCEPTION. 

in its obstetric sense, means the union of the male and female ele- 
ments of procreation : from which union a new being is developed. 
It is the means for the propagation of the species, and has variously 
been termed, fecundation, impregnation, fertilization, incarnation. 
We have considered the formation of the ova in the female ; we 
have seen how they were prepared for the reception of the male ele- 
ment. Xow we will consider the formation of the male element and 
how it reaches the ovum. 

The Testicle is the main reproductive organ of the male, and all 
the other organs must be considered accessory to it. It is composed 
of bunches of convoluted tubules of great length and intricate 
winding, surrounded by a strong, whitish, silvery membrane, the 
Tunica Albuginea, which dips down between the tubules as septae, 
carrying the vessels and nerves. These tubules, which are several 
feet long, are lined with several layers of epithelial cells, the lowest 
layer being inactive. The upper layers are active and are called 
Spermatoblasts. They become grouped together, the nucleus goes 
off to one side, the body of the cell becomes thinned out into a long, 
cilia-like filament, which projects into the lumen of the tube. Final- 
ly the cell becomes detached, having this shape, and is called the 
Spermatozoid. The head- represents the nucleus, the tail the cell 
protoplasm, so that the Spermatozoid is a real cell, and as it is de- 
rived from the primordial cells of the testicle, the union with the 
ovum, is the union of like morphological elements. 

The cells in the upper layers of the tubular wall do not undergo 
these changes, but become free in the lumen, mix with the semen, 



22 NOTES ON OBSTETRICS— JUNIOR CLASS. 

part of which they probably form by secretion. A fluid is present 
in the tubule and is probably from the large lymph spaces in the 
septae and around the ducts. 

The secretion passes along the vas deferens to the vesiculse 
seminales, where it is mixed with the secretion of those bodies. 

During cohabitation and ejaculation, the fluid is discharged from 
the vesiculse seminales, being at the same time mixed with the se- 
cretion of Cowper's glands, the Prostate and the Urethra. It is 
deposited in the posterior part of the vagina, and has the following 
characteristics : 

It is a thin, yellowish, white, creamy fluid, alkaline, mucilaginous, 
and has an odor peculiar to itself. The odor is due to a mixture of 
the various glandular secretions present in the sperma or semen, as 
it is called. Amount discharged varies from one to ten grams, but 
much larger amounts have been collected. Contains the spermato- 
zoids, the spermatic cells, epithelium, leucocytes, crystals. We are 
most interested in the spermatozoids. 

The number of spermatozoids in a given ejaculation is sometimes 
enormous. Lode, of Vienna, computed that there were 227,257,900 
in one specimen. 

These were formerly considered animalculse up to 1840, when 
KoUicker and Lallemand proved their origin from epithelial cells, 
while Landois gives their formation as from cilia, of the epithelial 
spermatoblasts. A spermatozoid consists of a head, a body, a tail 
and a terminal filament. The head is oval and on cross-section ap- 
pears like this ; on flat section . The tail has the 
power of rapid undulation, very much like the movement of cilia, 
by means of which the spermatozoid is moved from place to place. 
Proved by Spallanzini, 1768, that they are the active fertilizing ele- 
ments of the semen, and it is to them that I have always referred 
in speaking of the male element, and it is the union of a spermato- 
zoid with the ovum that constitutes conception, fertilization, or 
fecundation. This will serve as a definition. Fertilization is the 
union of the active male element of the semen of the male, the 
spermatozoid, with the product of ovarian activity of the female, 
the ovum. 

Where does this union take place? 

Some authors say the pavilion of the Fallopian Tube. Others 
claim the uterus ; others still, the peritoneal cavity. 

Owing to the frequent occurrence of pregnancy in the Fallopian 
Tube and its very rare occurrence in the ovary (only three cases 
on record), the authors are quite unanimous in placing the site of 
fecundation in the outer end of the Fallopian tube, called the pa- 
vilion. 

Spermatozoids, however, have been found all over the ovary, 
and even on the ovary of the opposite side, and it is probable that 



NOTES ON OBSTETRICS— JUNIOR CLASS. 23 

the union can take place anywhere from the ovary to the external 
OS, or wherever a spermatozoid finds an ovum ready to be fertilized. 
(J. Veit.) 

How does the ovum get into the tube? 

Several theories : 

1. That during copulation the fimbriated end of the Fallopian 
tube is erected and is applied to the ovary. Said to have been proven 
by post mortem injections of the blood vessels of the tube, but this 
has been denied by competent observers. 

2. Said that a stream of serum exists, passing from the ovary 
to the tube, caused by the ciliated epithelium of the fimbriated ex- 
tremity. 

Since the fimbriae of the tube are such delicate things, it is 
almost impossible to imagine how they could raise the heavy intes- 
tines above them and get on the ovary. Probably they have the 
power of directing the current of serum set up* by their ciliated 
cells. 

How do the spermatozoids reach the ovum lying in the pavilion 
of the tube? 

Again several theories which are more or less accepted. 

1. The semen is ejaculated directly into the uterus. Disproven 
by the anatomy of the parts. 

2. That the penis acts as a piston, forcing the semen into the 
uterus. Not plausible. 

3. That the uterus, in a state of erection, after coitus, relaxes 
and aspirates up the semen, which makes a pool in the back of the 
vagina into which the cervix dips. Some color to this view, but 
if so, the uterus ought to suck up the various germs, etc., existing 
in the vagina, which is contradicted by the fact that the uterine 
cavity is aseptic. 

4. That during copulation a piece of cervical mucus hangs from 
the cervix, and on relaxation this goes back into the uterus, carrying 
the semen with it. (Kristeller.) Same objection as to No. 3. 

5. Capillarity of the cervix. 

6. The spermatozoids get into the uterus by their own natural 
movements. This is the most generally accepted theorv, and is the 
most natural. The other factors may help, but that the wriggling 
motion is sufficient to bring a spermatozoid to the tube is shown 
by the numerous cases of fertilization where the semen has been 
deposited on the external genitals. 

a. Case of attempted rape, if the woman is strong enough, 

there is no jmmissio penis, and the semen may be dis- 
charged on the vulva. 

b. Cases of pin-hole hymen, where the same condition oc- 

curs ; pregnancv repeatedly takes place, semen being de- 
posited on the vulva. 



24 XOTES OX OBSTETRICS— JUNIOR CLASS. 

The cilia of the uterine epitheHum move toward the os internum, 
not, as heretofore believed, to the opening of the tube. The 
spermatozoids have to overcome this movement, which they do. It 
is said that they go at the rate of 3 m.m. a minute, but various ob- 
servers give different opinions ; one says an inch in seven and a half 
minutes. In a few hours the spermatozoids are found all over the 
tubes and ovaries. They find in the infundibulum of the tube, plenty 
of nooks wherein to wait for an ovum to come along. The spermato- 
zoids find the conditions favorable to life and they live, certainly a 
week, possibly longer, in the genitalia of the woman. Thus if the 
spermatozoids find no ovum when they come, they can wait till 
one is ripened and extruded. 

What happens when the ovum and the spermatozoids meet? 

Millions of spermatozoids die on the way to the tube and only one 
spermatozoid is needed or used in fertilizing an ovum. 

The spermatozoid reaches the ovum and penetrates the zona 
pellucida. This, according to Fol, of Geneva, is a soft substance 
and easily penetrable by the spermatozoid. It loses its tail, becomes 
round, is surrounded by a halo of radiating lines and progresses to- 
ward the female pronucleus. Fusion takes place and then the ^gg is 
fertile. The rest of the spermatozoids die and disappear. The 
ovum now proceeds to the uterus. The ciliated epithelia provide 
the mechanism, also the peristalsis of the tube. The uterine mucosa 
has already been prepared for its reception ; the ovum becomes at- 
tached to this, the cell divides by segmentation (Karyokinesis), and 
the fetus develops as you learned in your Embryology. Sometimes 
these changes do not occur as regularly as here laid down, e. g., 
the external and internal wandering of the ovum or of the spermato- 
zoids. 

The Corpus Luteiun. 

After the escape of the ovum with the Discus Proligerus and a 
little liquor folliculi out of the Graafian follicle, the follicle collapses. 
A small hemorrhage may occur in it, though not always. Owing 
to the increased vascularity of the parts because of the growing im- 
pregnated ovum in the uterus, the follicle takes on an increased 
growth. The cells of the membrana granulosa increase in size and 
number, and a yellow refracting body is developed in them, called 
lutein. Blood vessels develop in the mass from the membrana 
granulosa which is thrown into folds, and numerous white cells 
are found around them. 

The growth increases till the beginning of the fourth month, 
when the process begins to go backward. The collapsed Graafian 
follicle may have the size of a hazel-nut, is light yellow in color, has 
a zigzag outline, and is called a Corpus Luteum (yellow body). 

Toward the end of pregnancy the Corpus Luteum gets smaller. 



NOTES ON OBSTETRICS— JUNIOR CLASS. 25 

the contents being absorbed and the formed elements being changed 
into connective tissue, and several months after labor traces of it 
can still be made out, i. e., it leaves a small, retracted scar. 

If the ovum which came from the Graafian follicle does not 
become fertilized, the pelvic congestion incident to pregnancy does 
not occur, and the changes are very much less marked, and re- 
gression occurs quickly — say, at the thirtieth day, the scar left is 
small and sunken. 

The large Corpus Luteum of pregnancy is sometimes called a 
True Corpus Luteum. The small Corpus Luteum of menstruation 
is sometimes called a Fahe Corpus Luteum. It is usually possible 
to distinguish one from the other, but as Hirst has shown, the 
ovaries of two virgins, in which the Corpus Luteum of menstrua- 
tion was almost exactly like a Corpus Luteum of pregnancy, one 
cannot always be certain. 

The anatomical evidence of menstruation is the Corpus Luteum. 
It is these scars that distort the ovaries of every menstruating wom- 
an, and it was the scars of eight Corpora Lutea that Hyrtl found 
in the ovaries* of the girl who had died after eight menstruations. 

Function of Corpus Luteum. 

Born and Fraenkel say it is glandular, possessing an internal 
secretion which regulates the function of menstruation and preg- 
nancy. His and Qark say it develops the peripheral ovarian cir- 
culation, and prevents scar formation, which otherwise would, in 
time, destroy the functions of the ovary. 

We have described the normal migrations of the spermatozoids 
and the normal migration of the ovum, both fertilized and unfertil- 
ized. But these are not always so typical. Observers were struck 
by the occurrence of abnormal migrations. 

Case 1. Rokitansky. Case of animals with two-horned uteri, 
less number Corpora Lutea on one side than of fetuses on that 
side. A 



Woman with atresia of the left tube in pregnancy — ovum in the 
uterus, but Corpus Luteum in the left ovary. Called external 



zi'andering of the ovum, 



26 NOTES ON OBSTETRICS— JUNIOR CLASS. 

Case II, of Luschka. Small horn of uterus. Corpus Luteuni in 
other ovary. 



External Wandering of Ovum. 

Case III. Right tube obliterated. Pregnancy in the uterus and 
in the tube, which later ruptured. N. Y. Medical Gazette, 1870. 
Both Corpora Lutea in right ovary. 



It may happen by chronic pelvic peritonitis, the two tubes and 
ovaries are bound down near to each other behind the uterus, and 
thus the ovum easily passes to the wrong side. 

Case IV, from Weber Von Ebenhoff : Right tube obliterated. 
Corpus Luteum in left ovary. Pregnancy in right tube's end. 



Internal Wandering. 

It has long been believed that an ovum could wander down the 
tube of one side, through the uterus into the tube of the other side. 



NOTES ON OBSTETRICS— JUNIOR CLASS. 21 

But the case in the human which would support this theory has been 
questioned. In the Medical News, June 2, 1900, Morfit reports case 
of a woman whose right tube and ovary had been removed several 
years ago. She became pregnant in the stump of the right tube, 
which ruptured, hemorrhage, laparotomy. Recovery. Nothing 
said about pathological findings in the end of right tube. In ani- 
mals, if the ovary and the part of the tube of one side are ex- 
tirpated, ova are found in both horns of the uterus. 

This is simply the passage of the ovum from one horn to the 
other, and is not to be transferred to man. Thus far no positive 
case on record in the human. 

Case V. Double-horned uterus, one horn closed. Corpus Luteum 
on the side of closed horn ; pregnancy in closed horn. External 
wandering of the spermatozoid. 



How long does it take for the ovum to travel from the fimbriated 
extremity to the uterus? Not definitely known, but from analogy 
with mammals, placed at about eight days. Reichert has found 
the ovum in the uterus covered with the decidua reflexa fourteen 
days after the menstruation. 

The Determination of Sex. 

It is believed that there must be some law governing the produc- 
tion of male and females, because the proportion in nearly all coun- 
tries is 106 males to 100 females, and as the males have a higher 
mortality rate, this over-production serves to keep up the proper 
relation. What the law is, no one knows. The differentiation 
of sex occurs about the tenth week, that is, of the external organs, 
but the internal organs show this a few weeks earlier. 

Sex; may be determined : 

I. In the ovum itself. 
II. At the time of fertilization, by some action of the 
spermatozoid. 
III. Sex undetermined at first, but is influenced by external 
conditions in the first few months. 



28 NOTES ON OBSTETRICS— JUNIOR CLASS. 

The oldest theory was that of Hippocrates and Galen, who be- 
lieved the right ovary was for boys, the left for girls. Henke, in 
1786, believed that women could produce boys or girls at will, de- 
pending on which side they were lying at the coition. Cases where 
women with extirpated right ovaries having boys, and with only a 
right ovary having girls are common enough to refute this. Again, 
often at a post mortem, when the patient had a boy, we find the 
corpus luteum on the left side. That one ovary produces one sex, 
no one now believes, but the behef that the sex resides in the ovum 
and that there are male and female ozu is zmdely spread, the simi- 
larity of the sex of uni-oval twins tending to show this. 

Another theory is that of the age of the parents. Hofacker and 
Sadler. If the father is older, more boys ; if the father is younger, 
more girls. This does not hold good, and Ahlfeld has shown that 
old primipara have a plurality of boys. 

Janke's theory that the party weaker in the sexual act produces 
his opposite. That if a male child is wanted, husband should live 
on vegetables and the wife be nourished on the best of food. 

Thury's theory that ova of the beginning of heat, if fertilized, 
produce cows, later bulls. This is, to a degree, true of animals, 
but cannot be carried over to the human. 

The idea of Diising, that natural selection plays a part. That 
nature produces more of that sex which is necessary for the propo- 
gation of the species. This changes the w^ording of the proposition 
only. 

The theory of Ploss and Waldeyer. That the ovum is indif- 
ferent, but that emnroiiment alters it in the first weeks. Supported 
by the fact that in the lower forms of life, as melons and cucumbers, 
warmth, light and darkness produce males ; the opposite conditions 
produce females. According to these authors, even among animals, 
including the human, good surroundings produce females. But sev- 
eral observers, Rafifaeus and Breslau, wath 58^4 million cases 
used for statistics, have disproved this. But the occurrence of 
hermaphrodites and the fact that until the sixth w^eek organs exist 
which are neuter, speak for the theory, that sex is influenced by 
something later than conception. 

The theory of sex determination recently advanced by Dr. 
Schenk, of Vienna, is in line with that of Pryor, that the nutrition 
of the mother has a marked influence on the sex of the child. If 
the mother's health be raised, if her metabolism is so affected by 
conditions during pregnancy that sugar appears in the urine, the 
product of conception will be female ; if the patient is kept on a diet 
that will prevent sugar, or reduce the carbohydrates in the urine, 
the child will be a boy. According to Schenk, the state of maternal 
nutrition is evidenced by the amount of sugar or its equivalent in 
excreted carbohydrates in the urine. 



NOTES ON OBSTETRICS— JUNIOR CLASS. 29 

It would be well to wait for further experimentation and clinical 
reports before forming an opinion, though the evidence adduced by 
Schenk is little convincing. 

We must admit that we know next to nothing positive on the 
subject. 

Tiuic of Conception. 

Highly important to know at just what time the conception takes 
place, to be able to determine the date of confinement, and also to 
know how long an ovum must remain in the uterus for full develop- 
ment ; but our positive knowledge on this point is very limited. 
There are several factors involved : 

1. We must know the date of the coitus which fertilizes the 

ovum. 

2. We must know wdien the ovum left the ovary. 

3. We must know how long it takes the ovum to reach the 

tube, and the spermatozoids to reach the tube. The 
latter two points not known at all, while the date of 
coitus is uncertain — we must take the woman's w^ord. 

L Old Theory. Formerly, when it was beUeved that every 
four weeks an ovum was ripened and that this was simultaneous 
with the menstruation, it was believed that the ovum of the last 
menstruation was the one fertilized, and as far back as medicine ex- 
tends, the woman reckoned from the first day of the last men- 
struation. 

IL New Theory. Recently Loewenhardt and Reichert said that 
it was the ovum of the first period missed that is fertilized. That 
the ovum being fertilized, is developed on the Decidua Menstrualis 
and that the menstrual flow is, therefore, absent. Power says, a 
woman menstruates because she does not conceive : when she does 
not conceive she menstruates. 

IIL Thirdly, an ovum from between two periods may be fer- 
tilized, then the next period is missed and the conception dates 
from the middle of two periods. The spermatozoids can live several 
weeks in the passages of the female ; but an ovum has a much 
shorter life, possibly a week ; so that it makes little difference when 
an ovum is extruded, it may be fertilized at any time by a spermato- 
zoid lying in wait. 

I. Tliose authors - who believed it was the ovum of the last 
menstruation present which is fertilized, argued thus : 

At menstruation an ovum is extruded ; after menstruation copula- 
tion and fertilization take place, the next period is, therefore, miss- 
ing, — the woman is pregnant. If this theory is true it is very sur- 
prising that no one has had an abortion dating from the period of 



30 NOTES ON OBSTETRICS— JUNIOR CLASS. 

the last menstruation and the first one missed. Every gynecologist 
will pass a sound on a woman who has just had a period. If she 
has missed a period he will not do it. 

Further, the examination of young embryos almost always shows 
that they date from the first period missed. 

II. The New Theory that the ovum of the first menstruation 
missed is fertilized has many points in its favor. (Two just men- 
tioned.) Conceptions are believed to occur most often in the seven 
days after menstruation. The women know this, and often will 
not allow coitus till after the week or ten days, if they wish to 
avoid having children. Jewish law required this abstinence, saying 
that the woman was unclean till then, and they take a purifying 
bath on the seventh day. See Leviticus, Chap. XV, verse 19, and 
following. The women date their pregnancy from the first night 
when they are "clean" and can leave their bed of isolation for that 
of the husband. The Jewish women are very prolific, so this might 
prove something for the new theory, as it is not believed an ovum 
can live more than eight days after extrusion from the Graafian Fol- 
licle. 

It is the universal custom, however, to reckon nine months from 
the first day of the last menstruation. Clinical investigation of the 
subject is needed. 

While admitting that fertilization may occur at any time of a 
woman's active sexual life, the most conceptions occur after the 
last menstruation and before the first one missed. Thus we may 
have the time of pregnancy lasting 40 weeks, — 10 lunar months, 
or 43 or 44 weeks — 11 lunar months. Pregnancy lasts, on an aver- 
age, 280 days, so the 10 month type is. the more common. The 
season of the year has something to do with conceptions. The 
majority occur in Spring, May and June. 

In country districts during the harvest time, fewer conceptions — 
hard work. In countries where conscriptions for soldiers take 
place, there are many conceptions just before the conscriptions. 
Illegitimate conceptions occur most often in the summer months. 
Climate exerts some influence, the further north, in the cold regions, 
the less the frequency. 



THE PHYSIOLOGY OF PREGNANCY. 

We have followed the ovum up to its Fecundation and we have 
seen it form an attachment to the uterine wall. The zvoman is now 
pregnant. The period from now until she expels the product of 
conception, in labor, is called pregnancy. 

During pregnancy changes occur which affect every organ in 
the woman's body. It is an important epoch of her life. Defects 
which were latent may become apparent now ; her general resistance 
to outward influence is less ; she is more liable to colds, to infection, 
to nervous manifestations, neuralgias and many disturbances which 
we will consider later. 

The changes are : 

I. Local : — confined to the genitalia ; 
II. General : — of other organs in the body and the general 
m.etabolism. < 

Local Changes. 

The most marked change is in the uterus, which will be apparent 
when one considers that the virgin uterus is 2^ inches long and 
weighs a few ounces, whereas the uterus at the end of gestation is 
the size of a watermelon and weighs about two pounds (when 
empty). The ovum adheres to the decidua menstruaUs, and by its 
irritation, it causes a renewed growth of the mucous membrane. 
This changes it into the decidua graviditatis. This growth of the 
mucous memibrane is so active that it very soon grows over the 
tiny ovum. 

The ovum when it enters the uterine 
cavity is about i mm. in diameter. On the 
way to the uterus the ectoderm has devel- 
oped small projections on the surface (the primitive villi). These 
villi become attached to the surface of the mucous membrane of the 
uterus, dipping into it a little. The ovum may be caught in a fold 
of the endometrium. The villi, growing into the mucous membrane, 
carry the epithelium with them (syncytium). This is one theory. 
Most later workers believe the syncytium is ovular in origin. This 
layer breaks, and the villi grow directly into the connective tissue of 
the endometrium, i. e., into the mass of decidual cells, so that the 
epithelium of the ovum, the ectoderm, comes to lie against the con- 
nective tissue of the uterus. The ovum is then completely surrounded 



32 XOTES ON OBSTETRICS— JUNIOR CLASS. 

by mucous membrane, but the dififerent parts of the membrane are 
differently named. 

The part on which the ovum rests is called the decidua serotina. 

The part which has grown over the ovum, the decidua reflexa. 

The part which lines the rest of the uterus, the decidua vera. 

The manner in which the ovum is imbedded in the decidua is 
still subject to discussion. The recent publication of Peter's study 
of a very young ovum has not fully settled it, though this work is 
of great importance. 

Peters describes an ovum found in the uterus of a woman who 
committed suicide within a week of the cessation of the menses. 
It was the size of a hempseed. The ovum had burrowed into the 
mucosa, the point of entrance being marked by a tiny blood clot. 
The epiblast, or trophoblast, had worked into the decidua to the 
capillaries and its cells were in communication wath them. Inside 
the trophoblast, the mesoblast, a thin layer, was already showing 
by its growth, the formation of primitive villi. The outer layers of 
the trophoblast also showed, by absence of cell wall and presence 
of many grouped nuclei, the formation of syncytium. 

The decidua are now developed in accordance with the growth 
of the contained egg. This latter rapidly increases in size. The 
little villi of the primitive chorion form attachments to the decidua. 
The decidua reflexa is stretched by the growing ovum and is 
thinned very much. It is smooth on the outside, has no epithelial 
covering and is made up of roimd and spindle shaped, so-called 
decidua cells; it contains no blood vessels and soon begins to un- 
dergo a fatty degeneration which is complete at the end of preg- 
nancy. 

At the fourth month the decidua reflexa meets the decidua vera 
and they fuse together, forming a membrane as thin as a blotter, 
not separable, or only in part. The decidua is stimulated to grow 
even if the pregnancy occurs outside the uterus, e. g., in tubal preg- 
nancy. At the beginning of pregnancy it is about 7 mm. thick ; 
it increases to i cm. thick, perhaps thicker than the uterine wall, 
covering the ostia of the tube and sometimes the internal os, and 
from the third month on gets thinner as the growing ovum expands 
it? Toward the end of pregnancy they, i. e., the decidua vera and 
reflexa, are quite thin and microscopically are as follows : Next to 
the muscle is a layer of decidual cells, pierced by the glands, called 
the basal layer. On this is a layer loosely made up, a sort of flat- 
tened network of glands, called the glandular or ampullary layer. 
On top of this, the decidua thickens and the cells lie together in a 
compact layer called the cellular layer. The glands are spare here. 
The blood vessels come up to the surface around the glands in a 
cork-screw fashion, quite vertically. The decidual cells are devel- 
oped from the connective tissue of the mucosa, and are large, irreg- 



NOTES ON OBSTETRICS— JUNIOR CLASS. 33 

iilarly round, usually with one nucleus, but sometimes with many 
nuclei. The cells may sometimes be spindle-shaped and are charac- 
terized by their large amount of protoplasm. They have a peculiar 
jiabit of wandering about the pregnant woman and have been found 
in the brain, kidneys, lungs, and liver. Perhaps they form emboli. 
Have been by some regarded as pathological, especially in Eclamp- 
sia. They have been found from the sixth month of pregnancy 
on. The serotine decidua is quite thin and the distinction of an 
ampullary and cellular layer is not so marked — further the blood 
vessels are more developed and in piercing the decidua they lose all 
of their coats save the intima, spreading out in the form of sinuses. 

The separation of the fetus and its membranes from the mother 
takes place in the ampullary layer, i. e., at the expense of the 
mother ; sometimes the separation takes place in the cellular layer. 

AVhen the ovum enters the uterus, owang to the shape of the 
uterine cavitv. which on cross section is like this, it finds more 



opportunity to attach itself to the anterior or posterior wall than at 
the sides ; it finds very little chance on the fundus and this in accord- 
ance with clinical experience. At the sides of the uterus the 
decidua is thinner, and sometimes when the. ovum is extruded in an 
early abortion, say the second month, the decidua may present a 
sieve-like appearance in that portion from the corner of the uterus. 
We shall have occasion to refer to this point again when we come to 
describe the placenta. 

The old theory regarding the formation of the decidua was en- 
tirely different from the one just given. It was supposed that at 
the beginning of pregnancy the uterus was lined with a thick fibri- 
nous exudate. As this exudate was cast off at the end of preg- 
nancy (and also during menstruation) it was called a decidua. The 
fertilized ovum coming down the tube pushed the exudate ahead of 
it, therefore this part w^as called the decidua reflexa. Now a new 
exudate formed under the ovum binding it to the uterine mucosa, 
therefore called the decidua serotina (or late decidua), while the 
rest of the decidua was called vera. This is Wm. Hunter's theory 
and it is thus that the various parts of the decidua got their names, 
which are retained for convenience, although according to our pres- 
ent theory they are not ^good terms. The part, the mucous mem- 
brane of the cervix takes, is not settled. It is not quite certain 
that it forms no decidua, for recently a few cases have been pub- 
lished that show the placenta may become attached to the cervical 



34 NOTES ON OBSTETRICS— JUNIOR CLASS. 

mucosa, and we must conclude it becomes altered in a manner 
similar to that of the body of the uterus, in certain pathological 
conditions. Probably there are no specific changes in its mucous 
membrane, in the great majority of cases. 

Changes of the Muscle During Pregnancy. 

The normal uterus of a nulli gravida is a pear-shaped organ, 6^ 
cm. long, 2^ cm. thick and 4 wide, weighs 42 grams in nulliparae, 
in multiparae 55 grams. It is made up of hard unstriped muscle, 
covered in part by the peritoneum, moored to the pelvis by eight 
so-called ligaments and attached to the pelvic floor by means of the 
vagina. 

During the first half of pregnancy the uterus enlarges as the 
result of a hyperplasia of its muscular substance. This is true ex- 
centric growth, is much more rapid than is sufficient to accommodate 
the growing ovum and is not due to expansion by the growing- 
ovum, as the same changes occur in the uterus even when the ovum 
develops outside of it. It is a hypertrophy and also hyperplasia of 
the cells. The wall of the uterus, which was eight millimeters be- 
fore pregnancy, grows to be 25 mm. thick by the fourth month. 
This is the thickest it is during pregnancy, since from now on the 
itgg, growing, expands the uterus, the decidua reflexa coming to 
lie on the decidua vera. At the end of pregnancy the uterine wall 
may be four to six mm. thick. The cells increase in number and 
size.. A muscle fibre of the normal uterus is like this : A muscle 



fibre of the uterus at term is like this : Cells are said to be somewhat 
fibrillated. 

There are several layers of muscle in the uterine wall. These 
are arranged in a very complicated manner, crossing and recrossing 
each other, but in certain directions. There develops on the inner 
surface under the mucous membrane a special contractile layer, pos- 
sibly from embryonal elements hitherto undeveloped. 

The bundles of muscular fibres run from the peritoneal surface 
obliquely toward the mucous membrane and are laid one on the 
other like shingles on a roof. 

In general there are three layers of muscle, of which the external 
run more or less longitudinally ; the internal, more or less circularly, 
while the middle laver, which is more vascular, has lamellae which 



NOTES ON OBSTETRICS— JUNIOR CLASS. 35 

run in all directions. The fibres can be made out to pursue a course 
of circular rings around the tubes and internal os, and the longi- 
tudinal fibres of the tubes are continued fan-shaped on to the uterus, 
After labor the uterus contracts down into a hard ball about the 
size of a fetal head, is anteverted and has icalls^ 2 to ^^^ cm. thick. 
The fibres are shortened and the various lamellr.e of muscle are slid 
one on the other. 

The blood vessels undergo a hypertrophy and hyperplasia. The 
arterial supply of the uterus is derived from the uterine artery, 
which is a branch of the internal iliac, the ovarian, which is a 
branch of the aorta, and the funicular, a branch of the vesical 
which passes up the round ligament and goes to join the ovarian at 
the fundus uteri. 

The anastomoses are free and have a long spiral form, "cork- 
screws." The uterine artery gives off a branch just after it reaches 
the uterus about the level of the internal os. This branch encircles 
the uterus and anastomoses with its companion, forming the circular 
artery. Important to consider in certain operations on the cervix. 

The uterine artery then ascends along the side of the uterus 
to join the ovarian. This long corkscrew artery, from which many 
branches are given off, is sometimes called the Puerperal artery. 

The arteries in the uterus are surrounded by connective tissue, 
but lie between the muscular lamellae and may be compressed by 
the contracting muscular fibres or by superimposition of the layers 
of muscle. 

The veins are large spaces between the muscular bundles, lined 
by a single layer of endothelium ; these are called ''sinuses'' and are 
large, especially at the placental site, so that you can sometimes put 
your finger in them. They lead outward through the muscle of the 
uterus into a plexus at the side of the uterus, the uterine plexus. 
This is a large mesh of veins which lies at the side of the uterus and 
leads into the hypogastric vein, which empties into the internal iliac 
vein. The veins from the upper part of the uterus and Fallopian 
tube lead into the Pampiniform plexus. This terminates on the 
right side in the inferior vena cava, on the left side in the renal vein. 
These plexuses are of large size and important in the consideration 
of puerperal fever. 

The Lymphatics of the uterus begin as large spaces beneath the 
endometrium an-d in large numbers traverse the broad ligaments, 
communicating with stomatae in the peritoneum. The lymphatics 
of the corpus tUeri empty into the lumbar glands, those of the cervix, 
into the pelvic glands, those which accompany the round ligament 
empty into the upper set of deep inguinal glands, those of the lower 
vagina and vulva go to the superficial and deep inguinal glands and 
through these, with the glands around the external iliac arteries. 

The large size and great number of the lymphatics in and around 



36 NOTES OX OBSTETRICS— JUNIOR CLASS. 

the uterus must be noted and the distribution of the various streams 
of lymph is important in the consideration of puerperal fever. 

Change in the Shape of the Uterus. 

First in the anterior posterior diameter of the corpus. Often it 
seems that a certain part of the uterus is enlarged. The ovum 
situated in one part of the uterus softens and distends that part. 
This sign is of value in the early diagnosis of pregnancy. Thus the 
left side may be found large, thick and soft, and the right small, thin 
and hard, with a distinct groove between. The junction of the cer- 
vix with the corpus is softer than the rest. This allows the hands 
to compress the part below the body between them, sometimes almost 
together, thus : This is called Hegar's sign of pregnancy. 

After the second month it begins to enlarge laterally and the 
corpus begins to assume a round form. There is a real eccentric 
hypertrophy of the uterus till the fourth month. The cervix grows 
slowly up to the fourth month, after which little change in it except 
an increase in its succulence. The change is due to increase in the 
size of the elements with exudation. As the uterus enlarges it be- 
comes more anteverted and lies on the bladder. The fundus lies 
on the bladder, the cervix is directed backward ; the uterus lies heav- 
ily on the bladder, especially when the intra abdominal tension is 
increased. 

For the first three months, the uterus is entirely a pelvic organ, 
but now it rises above the brim and soon the abdomen begins to 
enlarge. Pinard says earlier. In primiparae the uterus is flattened 
out more antero-posteriorly is ovoidal. Its consistency is elastic, 
spongy^ soft. In multiparae the uterine body is more spherical. 

The uterus in the second three months (or trimester) is not so 
strongly anteflexed, rests against the abdominal wall, and bladder 
symptoms usually disappear if present. The body of the uterus is 
round, the cervix seeming like a little tumor adherent to the body. 
The increase in size begins now to be at the expense of the fundus, 
for the uterus begins to grow here. This is shown by the insertion 
of the tubes and round ligaments. 

At the end of the sixth month the uterus is at the navel. At the 
end of the 39th week it has reached the ensiform cartilage. Then 
the head sinks into the pelvis (in primiiparae) and the fundus of the 
uterus falls forward, sinking at the same time. It comes to occupy 
the level it had at the eighth month, but projects more in front. This 
process is called 'lightening." In multiparae these changes are not 
so constant, as the abdominal walls are relaxed. The posterior sur- 
face of the uterus is flattened while the anterior surface is convex — 
due to the fact that the posterior surface lies on the spinal column 
while the anterior wall is supported by the distended abdominal wall. 



NOTES ON OBSTETRICS— JUNIOR CLASS. 31 

The uterus at term is deviated to the right, in a large proportion 
of cases, at the same time it is twisted on itself — dextroversion and 
position. 

This condition is due to several causes : 

(i) General habit of sleeping on the right side. 

(2) Feces and gas in the sigmoid flexure. 

(3) Congenital twisting in growth. 

(4) Round ligament is shorter on right side. 

Thus in listening to uterine sounds, those from the left side are 
plainer, and this is why during certain operations, as Caesarean 
Section, the uterus must first be brought to the median line. The 
lx)sition varies with that of the woman. 

If she is standing, uterus falls forward and rests on anterior 
abdominal wall. 

If she is lying, falls back and to either side of the spinal column, 
but usually right. 

If she is lying on her side, falls to that side like a flaccid sac. 

The uterus pushes everything away from it. No intestines are 
between it and the abdominal wall. The intestines are forced up 
and to the left side almost alv/ays. The colon retains its usual posi- 
tion. The uterus exerts no direct pressure on the kidneys, liver, 
or the stomach, and thus is not answerable for certain trou- 
bles of these organs ascribed to it, e. g., nephritis, jaundice, inter- 
costal neuralgia, etc. It lies posteriorly on the promontory of the 
sacrum and lower lumbar vertebrae, the aorta and the ascending 
cava. 

The uterus in the last three months lies upon the ureters as they 
cross the pelvic brim; during this time, also, there is usually trac- 
tion on the bladder, which accounts for the bladder symptoms. These 
symptoms increase when the head has sunk into the pelvis, which 
occurs in primiparae in the last two weeks. This is called "lighten- 
ing" before labor. 

During pregnancy the bladder is a pelvic organ. During labor 
and the unfolding of the lower uterine segment the bladder is 
drawn up into the abdomen and becomes an abdominal organ ; the 
urethra is often stretched and becomes long, so you need a long 
catheter for labor cases. 

The capacity of the virgin uterus is 2 c. c, that of the uterus at 
term four or five thousand c. c. 

The Cervix and Lower Uterine Segment. 

The unimpregnated uterus is divided anatomically into two divi- 
sions — the body and the cervix. The cervix is about as long as the 
body and it is divided into three divisions, by the insertion of the 



38 NOTES ON OBSTETRICS— JUNIOR CLASS. 

vagina. The anterior wall of the vagina is inserted about i^ cm. 
from the external os. The posterior wall of the vagina is inserted 
about 3 cm. from the external os. 

The cervix extends above the vaginal insertion about .i cm. 

That portion of the cervix that is completely in the vagina is 
called the ''portio vaginalis" (c) ; that which lies behind in the 
vagina and in front against the bladder, the ''median portion" (b) ; 
and that above the vaginal insertion behind, the "supra-vaginal por- 
tion" (a). 

The cervix during pregnancy becomes softened, by imbibition, 
and a moderate hypertrophy of its elements occurs. Softening goes 
from below upward ; the mucus glands secrete freely. There is, 
however, no distinctive line between the muscle of the cervix and 
that of the corpus uteri. The question as to whether the cervix 
does or does not take part in forming the cavity of the uterus for 
the growing ovum has been argued for years. 

There are two theories, — really two schools, — and the polemic 
was formerly very sharp, but now a middle position is being taken, 
a tendency to which is evinced in many other places in Obstetrics. 

Old Theory. The Vienna theory, or that of Bandl. 

That from the fifth month on, the upper part of the cervix was 
dilated and drawn up to assist in forming the cavity of the uterus. 
That this process continued and that at the end of pregnancy the 
vaginal portion only remained unused and needed to be dilated by 
the contractions of the titerus. According to this theory a uterus 
at term would be like this : 



II. Schroedefs Theory. The New Theory, or that of the Berlin 
School. 

That the cervix was not used for the cavity of the uterus ; that 
the OS internum remained closed till very near the advent of labor; 



NOTES ON OBSTETRICS— JUNIOR CLASS. 39' 

that the lower uterine segment was formed entirely from the lower 
part of the uterus. Stoltz, as early as 1826, taught this theory. 



The anatomy is the same in all cases, the opinions differ as to 
where the Lower Uterine Segment comes from. Above the contrac- 
tion ring the muscle bundles are thickly placed together and the con- 
nective tissue is not so thick. Below it, that portion which is dilated 
10 form the lower uterine segment, the wall is thin, relaxed, the 
muscular bundles are separated from, each other and are few, and 
there is a larger amount of connective tissue. The peritoneum is 
loosely attached here. The bearing this has on the pathology of 
labor will be considered next year. 

We believe that the lower uterine segment is mostly derived 
from the corpus, but that when the dilation begins in pregnancy, as 
it generally does in primigravidae, the upper part of the cervix takes 
a certain part. 

In multiparae, however, the lower uterine segment is not formed 
till near labor and the os internum remains, therefore, closed till 
the onset of regular uterine contractions. 

There are several arguments which support the old theory : 

1. Preparations sometimes show relics of the arbor vitae of the 
cervix spread out over the lower uterine segment. 

2. The membranes are adherent to the uterine wall only to a 
point near the internal os. It is held that the cervical mucus mem- 
brane cannot produce decidua. Recently cases reported, however, 
where the placenta was attached to the cervix. 

3. On examination of the uterus per vaginam, just before labor, 
it is possible to feel an external os, internal os, and above this a 
third ring, which seems lo come from an unfolding of the upper 
portion of the cervix. 

Most preparations of uteri during pregnancy show the cervix 
closed throughout its length. Practically it makes little difference 
which theory one accepts. Suffice to know the anatomical and clin- 



40 NOTES ON OBSTETRICS— JUNIOR CEASS. 

ical differences between the lower uterine segment and the fundus 
of the uterus. 

The peritonemn of the uterus grows with it, as only in patholog- 
ical cases do we find scars, and later in labor it is thrown into 
minute folds which run in certain directions, e. g., transversely, ob- 
liquely and longitudinally, corresponding to the underlying muscle 
bundles. The surface of the uterus at term is twenty times that of 
the unimpregnated state. 

To a certain extent the peritoneal covering of the uterus at term 
is derived from the broad ligaments unfolding and the uterus devel- 
oping between the two plates of the ligament. 

According to Schmorl there are decidual growths on the peri- 
toneal surface of the uterus and on the ovaries. These may be 2 or 
3 mm. thick. Sometimes they are found on the omentum. Resem- 
ble, in appearance, miliary tubercles. They are just under the endo- 
thelium, raising it up. Are found from the third month to the 
tenth, mostly later. 

The Round Ligaments. 

These enlarge, the muscular elements hypertrophy and increase 
in number, the ligaments may be as thick as the httle finger, are 
inserted more anteriorly on the face of the uterus, and owing to the 
higher position of the uterus in the abdomen, the Round Ligaments 
run more vertically. 

Their function is to moor the uterus anteriorly to the pelvis. 
They can generally be felt; almost always the left one can, owing 
to the deviation of the uterus to the right side, and they are used 
to determine the site of the placenta. As they are moored to the 
fundus of the uterus, the retraction of the fundus away from the 
pelvis puts them on the stretch and this is an important sign in 
threatened ruptura uteri. When the placenta is situated on the ante- 
rior wall the round ligaments run at the side of the uterus. When 
the placenta is on the posterior wall they run in front. 

The Utero Sacral Ligaments develop, the unstriped muscle fibre 
in them increases in size and amount, they pull the cervix backward 
and with the round ligaments serve to keep the axis of the uterus 
perpendicular to the inlet of the pelvis. 

The Fallopian Tnhes become thickened, soft, more vertical ; the 
uterine ends are closed, as a rule, but not always ; the fimbriated end 
is open. 

The Ovaries are somewhat enlarged, especially the one contain- 
ing the Corpus Luteum. The ovary may be palpable on the left side 
(Budin). The other ovary is behind. They are often painful and 
tender. 

The Pelvic Connective Tissue loses its fat to make room for the 
passage of the child. The unstriped muscle fibres become developed 



NOTES OX OBSTETRICS— JUNIOR CLASS. 41 

in it, the lymph spaces are larger, the whole pelvis is in a state of 
congestion and is more succulent. 

The Vagina increases in length and capacity by a real eccentric 
hypertrophy. It becomes very distensible, the veins increase in size 
and number, the mucosa is infiltrated, undergoes hypertrophy which 
deepens the folds it normally has ; the papillae swell up so that 
sometimes they are palpable, as small granules. If the case is gon- 
orrheal they become as large as a pea. Still they may be quite large 
and yet normal. It takes on a deep blue color (referred to later) 
and is soft. This begins in the first week of pregnancy and is af 
useful sign diagnostic of pregnancy. 

The secretion is increased very early in pregnancy, and the 
patient may come to you for the leucorrhea. 

When the uterus ascends, it draws the vagina upward. When 
the head is in the pelvis, it is sometimes thrown into circular folds 
which may simulate the partly dilated cervix. There may be a 
prolapse of the anterior vaginal wall. 

The Vulva undergoes the same changes — softening, dark colora- 
tion, thickening, enlargement, so that the vulva may be patent. It 
becomes somewhat pigmented, more distensible. 

The Periiieuui has the same changes and these are calculated to 
allow the great distention necessary for the passage of the child. 

CJmnges in the Pelvic Floor. The pelvic floor may be considered 
a mass of muscular, connective and fatty tissue filling up the outlet 
of the true pelvis, covered below by the skin, and lined above by 
peritoneum. The bladder and uterus lie on it, it is pierced by the 
urethra, the vagina and rectum. The main muscle in it is the levator 
ani-coccygeus. The function of this part of the pelvic floor will be 
described more fully later. 

There are two systems of structures in the whole pelvic floor, 
which are called segments, a pubic and a sacral segment. The 
pubic segment is made up of the bladder, urethra, anterior vaginal 
wall, and the fat and blood vessels behind the pelvis. It is loosely 
attached in front to the pelvis, and at the sides blends with the 
sacral segment. 

The sacral segment is firmly attached to the sacrum and coccyx ; 
it has the strong levator ani-coccygeus, the fascia above and below 
it, the posterior wall of the vagina, the perineum below. These 
segments then overlap, thus : 

During labor the pubic segment is pulled up and the sacral seg- 
ment is forced down. The action has been likened to one passing 
through folding doors.'pulling one toward himself and pushing the 
other away. As a result of this the bladder and urethra and anterior 
wall of the vagina are drawn up into the peritoneal cavity, the sacral 
segment is pushed down and backward. 

The pelvic Hoor projection is the projection of the perineum 



42 NOTES ON OBSTETRICS— JUNIOR CLASS. 

below a line drawn from the sub-pubic ligament to the tip of the 
sacrum. It is increased during pregnancy, by the growth and sag- 
ging of the pelvic floor ; increased in retroversion of the gravid ute- 
rus, and anything that increases intra pelvic tension. 

The Pelvic Joints undergo the same general imbibition ; the cap- 
sule gets thicker ; the synovial fluid increases ; the joint becomes more 
movable. The coccyx and the symphysis pubis mostly affected. 
The movability of the joints in the olden times was considered 
absolutely necessary for delivery, but now this is not so considered. 
Still the softening certainly does do good in certain cases and we 
make use of it in labor sometimes. The movability may develop so 
markedly that the patient has a wobbling gait in the last months 
of pregnancy, or may not be able to walk at all. Certainly a good 
many of the pains during walking of which pregnant women com- 
plain are due to relaxation of the pelvic joints. 

The Bladder early in pregnancy can rise up into the abdomen 
when it fills. The uterus lying on it does not produce the frequent 
urination and the bladder symptoms complained of by gravidae. 
These symptoms are due to the stretching of the base of the bladder 
caused by the anteverted uterus and to changes in the pelvic circu- 
lation due to pregnancy. Late in pregnancy, the bladder, when 
filling, has to occupy a place between the uterus and abdominal wall 
and is therefore flattened and its capacity diminished. Thus is 
explained the frequent urination at this period. That the bladder 
suffers direct pressure is only possible very near term and in patho- 
logical conditions. Varicose veins in the pelvis may also explain 
bladder symptoms. The ureters are displaced to the side and up- 
ward. They rarely suffer compression. Obstruction is more likely 
to be due to distortion; both are rare. They may be felt through 
the bladder vaginally and are said to be enlarged during pregnancy. 

CHANGE IN THE PHYSIOLOGY OF THE UTERUS. 

It acquires no new functions ; those it has, however, are very 
much increased. 

1. Sensibility — not much, but sometimes may be painful to touch 
and to fetal movements. Varies much in different women. 

2. Irritability is that property which makes the uterus respond by 
contraction, to external stimuli. This increases much in pregnancy, 
but often this varies with the patient, some patients, the least ab- 
dominal manipulation causes contraction of the uterus. 

3. Dilatability is increased very much. 

4. Contractibility, that power which the uterus possesses of con- 
tracting and therefore diminishing its cavity. In the unimpregnated 
uterus this is shown by the expulsion of clots, tumors, membranes, 
etc. During pregnacy there are regular painless contractions of the 



NOTES ON OBSTETRICS— JUNIOR CLASS. 43 

uterus (B. Hicks, 1871). These last 20 to 30 seconds, are quite pain- 
less and are quite irregular as to time. 

During labor this ponder (4) becomes much increased, but with 
the exception of pain, the contractions are the same as those during 
pregnancy. The nature of the uterine contractions : — 

(a) They are involuntary ; 

(b) They are slow, they go to acme and decrease ; 

(c) They are intermittent, but at irregular intervals during 

pregnancy. During labor they are quite regular. 
5. Retractibility, or Tonicity, is that property of the muscle 
which causes the uterus to exhibit a tendency to revert to its virgin 
form. Exists alongside of contractibility. 

Changes in the Ahdominal Wall. 

As a result of the growth of the ovum, the abdomen becomes dis- 
tended and the wall gets thinner. In primiparae with tenser muscles 
this is less marked. Sometimes the recti muscles are separated and 
the pregnant uterus may fall forward between them. "Ventre en 
besace." 

The Physics of the Abdomen. 

Durmg life the pressure in the abdomen is slightly less than 
that outside. This is shown by the inrush of air during laparotomy. 
Inspiration increases the pressure, expiration decreases it. The 
changes in the pressure brought about by respiration are transmit- 
ted throughout the abdomen, are evident on the perineum and or- 
gans resting on the pelvic floor, uterus, bladder. The organs of 
the abdomen are under constant pressure, from the muscles of the 
abdominal walls and the atmospheric pressure. This contributes 
greatly to their support. The liver is too heav}' to be supported 
only by the ligamentum suspensorium. 

M. Duncan says that the "retentive power" of the abdomen 
holds the organs in place. What this is, is indefinite. During preg- 
nancy the growing uterus fills out the abdomen and increases the 
intra-abdominal pressure. This gives rise to many symptoms and 
conditions to which we w^U refer often. 

In addition, the vertical pressure in the abdomen increases from 
above downward just as in a column of fluid, when the individual 
is erect. 

The skin shows in 90% of the cases (Crede) purplish, smooth, 
broad lines called linea gravidarum, or striae gravidarum. They 
occur most often on the breasts, nates, and thighs, sometimes as far 
down as the knee, before and behind. 

These marks are not characteristic of pregnancy, as they occur 
with abdominal tumors and where there is a sudden increase in fat, 
e. g., young girls at puberty. Unusually rapid growth of the long 



44 NOTES ON OBSTETRICS— JUNIOR CEASS. 

bones, may cause them, at the epiphyses. Schultze found them in 
36% of cases not pregnant and 6% of men. 

The connective tissue of the cutis and subcutis tissue is stretched, 
sometimes torn, and the lymph spaces are arranged in parallel lines. 
When they are old they become white like a scar and show a fine 
folding. Some patients have many striae, some few. Blondes 
usually a little more likely, still colored people have them. 
The striae are usually mostly below the navel and seem to form cir- 
cles around it. When they are on the thighs they converge toward 
Poupart's Ligament. Not always due to pregnancy. May be sequel 
of typhoid. 

Changes in the Breasts. 

These are developed as early as the third month of embryonic 
life. There are several tubular glands around the position of the 
future nipple. 

In the fetus at five months, the glands exist simply as a collec- 
tion of ducts which open at one spot. These are branched blind 
ducts from which the different lobules of the gland are later formed. 

, In the new-born child the ducts divide two or three times, but 
no true acinous structure is formed till puberty, when the acini are 
developed from the tubules at the periphery of the gland. 

During pregnancy the change is still more marked, the acini 
being formed all through the gland. 

The development of the mammae in girls" is very slow till pu- 
berty, then it takes new life. Each of the preliminary tubules be- 
comes changed into a racemose gland, and thus the breast comes to 
be nmde up of distinct lobules. These empty by ducts on the sur- 
face of the nipple, which has become somewhat prominent. Before, 
it existed often as a little depression. The nipple is quite vascular, 
pigmented and has unstriped muscular fibres at its base, which when 
irritated, contract, throwing the nipple into a state of erection (suit- 
able for suckling) . There are fifteen to twenty of these openings on 
the surface of the nipple, the opening being smaller than the duct. 

The fine milk ducts have an enlargement before they open on 
the surface of the nipple, the sinus lactiferus. 

After pregnancy has occurred the changes take a new start and 
as early as the second month are quite marked. The breasts increase 
in size and sensibility, the nipple becomes more erectile, the veins 
enlarge and are seen as blue streaks, especially at the periphery of 
the gland. Striae gravidarum develop. The areola around the nip- 
ple becomes more deeply pigmented, called the ''primary areola." 
Little prominences previously not marked now appear here, they are 
tiny milk glands which are called tubercles of Montgomery. 

Sometimes around this primary areola, a second areola is formed 
which is not so deeply pigmented. Looks like water sprinkled on 



NOTES ON OBSTETRICS— JUNIOR CEASS. 45 

dusty paper. The clear spots are due to a lack of pigment around 
the openings of the sweat and sebaceous glands. 

The gland now begins to secrete a clear watery fluid with a yel- 
lowish admixture, called colostrum. May be pressed out, but some- 
times comes alone and may prove annoying to the patient. 

The blood supply of the g-land is derived from the internal mam- 
mary, the infetior thoracic, the acromio-tnoracic and intercostal 
branch. 

The internal mammary artery divides, sending off the superior 
epigastric, which in turn anastomoses with the deep epigastric, and 
this with the external iliac artery. 

The veins are collected into a circle around the edge of the 
gland called the ''circulus Halleri," and empty into the axillary vein. 

After labor the glands suddenly take on the most active opera- 
tion they have yet done, and this we will consider at the proper 
time (puerperium). 

The mammary gland may be considered a modified gland of the 
skin resembling the sebaceous glands. Sometimes we find an extra 
mammar}^ gland below the ordinary gland. Sometimes one is found 
on the back or thigh. 

This is called polymastia and is very rare. The left gland is usu- 
ally larger than the right. 

There is the belief derived from embryologic studies that man 
had at one time a line of glands running from the axilla down on 
the abdomen, like some of the low^er animals. Accessory glands and 
nipples are almost ahvays found on this line. 

Up in the axilla there is often a piece of mammary gland wdiich 
swells and becomes painful when lactation starts. This is often 
mistaken for a lymphatic gland, but is really a prolongation of the 
mammary gland. It needs no treatment. 



CHANGES IN THE MATERNAL ORGANS. 
General Changes. 

Mauriceati says pregnancy is a disease of nine months' duration. 
That there is some truth in the statement, no one will deny. Gener- 
ally, however, the pregnant state and labor are looked upon as physi- 
ological, and often this is used as an argument for non-interference. 
Still there is no other function of the female that is attended with 
such dangerous possibilities, therefore, while looking on the func- 
tion as physiological, we must always bear in mind that at any 
point it may become pathological, and perhaps fatal to either or both 
mother and child. 

A pregnant woman ought to feel as well as during the non-preg- 
nant state. In a large per cent of the cases they do, or even feel 
better, but often they are not so. They are more irritable ; their 
character changes ; they are less trustworthy ; they are less tidy ; 
they have various aches and pains, neuralgia (toothache), headache 
and innumerable symptoms which the doctor is called upon to alle- 
viate during the nine months in which she is carrying child. Some- 
times severe mental disturbances arise. Every organ in the body 
feels the stimulus of pregnancy. 

The Changes in the Blood. 

These have been differently described at various times. Eor- 
merly believed that the blood was watery, a decrease in the red and 
white blood corpuscles occurring. Was called the hydremia of preg- 
nancy, or ''serous plethora" (Kiwisch). Many theories as to the 
causes of various conditions of the pregnant state, and of accidents 
to the pregnant state (e. g., eclampsia) were based on this supposed 
condition of hydremia ; but this assumption rested on clinical grounds 
only, new instruments of precision dispelling it. 

While in the first few months of pregnancy there may be slight 
reduction in the reds, and increase of the whites, the system soon 
reacts to the necessities imposed by the pregnancy and there is an 
increase of the reds, also of the whites, the latter out of proportion 
to the reds. (The '''physiological leucocytosis of pregnancy," Vir- 
chow.) In the latter half of pregnancy a true plethora exists. The 
need for more blood must be admitted ; the addition of the fetus 
and the fetal circulation, the development of the uterine arteries 
and veins, the enlargement of the veins of the lower extremities, so 



NOTES ON OBSTETRICS— JUNIOR CLASS. 47 

that they hold a great deal of blood. It would seem that they act 
as reservoirs to compensate for the loss of blood at labor. The loss 
of a pint, sometimes, to a quart of blood after labor, usually makes 
no symptoms. Women gain absolutely in weight in the latter half 
of pregnancy. 

The amount of hemoglobin is increased in proportion to the num- 
ber of reds. The amount of albumin is decreased. Alkalinity of 
the blood is increased. In weak, poorly nourished women, especially 
those women that are poor, w^orking in factories, a condition of 
chloro-anemia develops. 

In the latter half of pregnancy the fibrin is increased to about 
one-third more in amount than in the non-pregnant state. The prob- 
able use of this is to favor thrombosis in the vessels after labor and 
thus prevent hemorrhage. Thrombosis sometimes occurs in the legs, 
or in the pelvis before labor. Leopold says that clotting occurs in 
some of the vessels at the placental site before labor. Occasionally 
a piece of one of these thrombi becomes dislodged and gets into the 
lungs, when sudden death may occur. 

The blood-making organs take on an increased activity. The 
thyroid enlarges and becomes more vascular. The enlargement 
decreases after labor, but never to its former size. The thyroid is 
said to have a bearing on toxemia and eclampsia (Lange). 

The spleen increases in size, perhaps one-fourth of its original 
weight, from 140 to 180 grams. Lumbar glands enlarge. 

On the inside of the skull there are deposits of reddish plates, 
composed of triple phosphates — calcium salts — really of bone. Oc- 
cur mostly along the middle meningeal artery and the longitudinal 
sinus. Every pregnancy, a new layer, so that one can count the 
pregnancies in favorable cases, by the number of layers. May occur 
in the pelvis also. Called by Rokitansky "Puerperal Osteophytes." 
Supposed to have some function for the blood or for the nourish- 
ment of the fetus. They are about i or 2 mm. thick, and occur in 
about one-half of cases. Not characteristic of pregnancy, since they 
sometimes occur in syphilis, tuberculosis, chronic hydrocephalus. 

The changes in the circulatory organs are marked. The heart 
undergoes an eccentric hypertrophy, especially of the left ventricle. 
This point was first brought out by Larcher in 1827. There are 
several reasons for the acceptance of this theory. 

1. The physiological need for more work by the heart, e. g. : 

( 1 ) The increase in the amount of blood ; 

(2) The new placental circulation ; 

(3) The increased intra-abdominal tension. 

2. Anatomical Endings. Blot said there is gain of one-fifth, 
especially left ventricle. This is not constant. 

3. Physical examination shows the hypertrophy. 



48 NOTES OX OBSTETRICS— JUNIOR CLASS. 

There is an increase in the area of cardiac duhiess, but this may 
be explained by the fact that the anterior portions of the lungs retract 
somewhat and leave more of the heart uncovered. Said that dia- 
phragm rises higher, and thus displaces apex upward, giving the 
appearance of an increase of cardiac area. There is often (one in 
four) a systolic bruit over the base of the heart; this is a so-called 
hemic murmur and disappears after labor. Has often been mistaken 
for an organic murmur. The pulse is harder, larger and often more 
frequent than in ordinary conditions. This agrees with the findings 
of the heart. This hypertrophy of the heart is not admitted by all 
authors. The venous pressure below the pelvic diaphragm is in- 
creased, above this, the arterial pressure is increased. Formerly 
said that the pressure of the gravid w^omb on the veins of the abdo- 
men caused the congestion below, but this is not so. The conoestion 
is due to increased intra-abdominal tension. 

The uterus is a relaxed sac and does not press on the vessels any 
more than the intestines, which are of about the same specific grav- 
ity. Ascitic fluid is often of the same specific -gravity as the preg- 
nant uterus, and the uterus may be regarded as like this, as the level 
of the liquor amnii is liable to change. The congestion (venous) is 
shown by the varicose veins of the lower extremities, vagina and 
vulva, and the hemorrhoids. The edema perhaps comes from this. 

In some cases of venous congestion, even pronounced varicosities 
develop long before the pregnancy is so far advanced as to cause an 
increase of the intra-abdominal tension. Related of a certain cook 
that she knew she was pregnant by the beginning of varicosities in 
the legs, wdiich began as early as four weeks. Cause for this must 
be looked for in the vaso-motor system. These varicosities are not 
always due to mechanical causes. There is often some congenital 
anomaly of the veins brought out by pregnancy, or some special 
action in the pregnancy itself. It mav be absent when one would 
expect it present and thus may be used in diagnosis. Writer had a 
case of carcinoma of the ovary, with a tumor blocking the pelvis 
and affecting the peritoneum, marked ascites. Ballottement was 
obtained and a diagnosis of pregnancy had been made. There were 
no varicosities, which is remarkable because the abdominal circulation 
was more disturbed than by a pregnancy. (Wm. Waager, 1901.) 

Sometimes there are attacks of palpitation with a sense of suffo- 
cation. These are probably not due to hypertrophy, but to irregu- 
larity in the nervous mechanism of the heart, perhaps from a full 
stomach. Occur more often in nervous women. Regulation of the 
diet (non-nitrogenous), laxatives, generally cure the cases. Women 
not seldom have fainting spells during pregnancy. Sometimes they 
are real, with pallor and poor pulse. Sometimes hysterical. Some 
are due to toxemia, though what kind I do not know. They get 
well with regulation of diet and stimulating the emunctories. 



NOTES ON OBSTETRICS— JUNIOR CLASS. 49 

The Lungs. 

The anterior part of the diaphragm is pushed up. The chest is 
expanded, laterally, diminished anteriorly, and the whole thorax 
lifted up during pregnancy. The vital capacity is not decreased, 
however. In primiparae (see Vejas Volkman's Klinische \"ortrage) 
it is a little less than multiparae, owing to lax abdominal walls in 
the latter. Breathing less diaphragmatic, more costal. More CO^ 
excreted. The temperature is not changed, nor are its variations. 
At the end of pregnancy the uterus sinks, relieves the chest. 

The Urine. 
(See Von Noorden Path, des Stoffwechsels, page 136.) 

Quantity increased about one-fourth. The solid constitutents, 
however, for a whole day are the same, for a single specimen less, 
i. e., the specific gravity is low. 

It is supposed that there is some hypertrophy of the kid- 
neys, and reasoning from analogy, this is probable. A whitish pel- 
licle sometimes forms on the urine after it has been standing for 
thirty hours, called Kyestein, but has no significance as to preg- 
nancy, since it occurs in the urine of men. Amount of urea de- 
creased. 

Sugar is sometimes found in the urine, and has been ascribed to 
two sources : — 

1. The breasts, lactosuria. 

2. An increase of the glycogenic activity of the liver. 

If the lactose is slight in amount and not attended with symp- 
toms pointing to a disturbed nutrition, it is not bad, but favorable 
as meaning a good milk secretion. The relation of lactosuria to the 
determination of sex has already been referred to. Lactosuria oc- 
curs in about 16%. True glycosuria is occasionally found, but the 
sugar is minute in quantity. It should be looked upon as patholog- 
ical, and the patient put under close surveillance. 

Albumin is in a certain percent of cases found in the urine 
during pregnancy. Schroeder says 5%. But taking all cases of 
albuminuria together, it will be as high as 30% (Palmer). My 
own experience shows about 3% — about as much as is found in 
healthy people. Renal albuminuria is almost never normal in preg- 
nancy, therefore look on all cases with suspicion. Sometimes find 
a few white blood cells and red blood cells ; said even that occa- 
sional hyaline casts are ' not pathological ; their occurrence, never- 
theless, warns us to watch carefully. Albumosuria occurs in 25% 
of pregnant women (Fischel) in small quantities. Said to come 
from the liquor amnii. The urine of healthy pregnant women is 
not so poisonous as that of non-pregnant women under the same 
conditions of diet, etc. Deduced from this that toxines are stored 



50 NOTES ON OBSTETRICS— JUNIOR CLASS. 

up in the blood. Chlorides increased. Phosphates and sulphates 
decreased (used by the fetus?). 

Skin. 

(See Montgomery, Diag. P'g.) 

Increase in the subcutaneous fat. Pigmentation occurs at the 
places where fetal folds joined, e. g., the linea alba becomes a 
iinea nigra, navel grows darker. The nipples, the vulva, sometimes 
the face, brow and each cheek have a dark brown pigmentation 
which is sometimes speckled. This last may be very marked and is 
then called the *'mask of pregnancy." Nervous women, or women 
suffering from uterine disease, sometimes have it. It is called 
"chloasma uterina." There is also sometimes noted a discolora- 
tion of the eyelids, which may be of three kinds : — 

1. Venous congestion; 

2. A deposition of pigment in the rete, and 

3. A kind of Stearrhea Nigricans, where the pigment can be 
wiped off (rare). These pigmentations disappear after labor, but 
if they have been marked a trace often remains. The pigmentation 
is due to slow circulation at the site of the junction of folds, due 
to narrow capillaries. Some authors say a hypertrophy of supra 
renals. (Awaits post mortem proof.) Easier to say it is neurotic. 

The red blood cells break up more easily during pregnancy and 
this may account for ease of pigmentation. (Ahlfeld.) 

Brunettes are more affected than blondes. Hair takes on an 
increased growth which usually disappears after pregnancy. Hair 
may fall out after pregnancy. The sebaceous and sweat glands in- 
crease in activity, and these favor in untidy people pityriasis versicol- 
or. The finer features of the face are made coarser, the patient 
has a florid face often, is liable to flushing. Esbach has determined 
a thinning of the nails. 

Bones. 

The bones become vascular, but undergo no changes. The 
changes of the pelvic joints, already mentioned. The spinal column 
is straightened, due to the center of gravity being changed, owing 
to the tumor in the abdomen. The small of the back is sharply 
curved. 

This gives the patient a peculiar gait or strut. The shoulders 
are thrown back, the head erect, the feet thrown out straight ahead ; 
called by Shakespeare the "Pride of Pregnancy." 

There is a diminution of the lime salts if not sufliciently taken by 
the mother in the food. Teeth earliest affected, therefore old saying, 
"Every child a tooth." Said that fractures unite poorly in preg- 
nancy. 

Prevalent idea that if lime be left out of food, the child's bones 



NOTES ON OBSTETRICS— JUNIOR CLASS. 51 

will be softer and labor easier. This is true only to a slight extent, 
but is dangerous for the children, as they frequently develop rachi- 
tis. 

Digestive Tract. 

Salivary secretion is increased. Sometimes there is ''cotton 
spitting," i. e., expectoration is frothy ; perhaps the salivation be- 
comes pathological and needs treatment. Teeth easily become bad, 
sometimes cavities develop, due first to the alteration in the secre- 
tions of the mouth, dentists say. 

Second, the demand of the fetus for more calcareous salts. The 
salivation begins about the sixth to the eighth week and lasts till 
the third or fourth month. Occasionally persists. Gingivitis of a 
mild degree is not uncommon, may become pathological. 

The Morning Sickness. 

Often early in pregnancy, sometimes as early as the second 
week, or third week, patient has nausea and vomiting and usually 
continues till the fourth month, sometimes later. This occurs in the 
morning, often on an empty stomach, or after breakfast, seldom 
after the other meals. It occurs so often as to be considered normal. 
Mostly m primiparae, but not rare at all in multiparae. The patient 
has the nausea on raising head from the pillow and m.ay vomit some 
sour mucus. Any sudden motion may cause it. It is similar to sea- 
sickness. 

Should the vomiting be after meals, and recur more than once 
during the day, or there be a constant nausea, the case belongs to 
the pathological and will be considered in the pathology of preg- 
nancy. 

Cause is obscure. Probably a reflex from the uterus. Occurs 
more in the higher classes of society. Vomiting may recur in the 
latter months of pregnancy, just before lightening, due to displace- 
ment of intestines and the stomach. This ceases after head has 
gone into pelvis. But the vomiting at this time may be due to ure- 
mia. Be watchful. 

The Taste. 

Is often perverted, patients having a desire for unnatural things, 
such as chalk, slate pencils, herrings, etc. ; called ''Pica.'' Case 
where a woman craved the flesh of her husband and killed him and 
ate him, and salted part of him down (Barnes). 

Appetite. 

Usually increased, unless nausea occurs, even then, after the 
vomiting, appetite very good ; sometimes women feel acute hunger. 



52 NOTES ON OBSTETRICS— JUNIOR CLASS. 

The Stomach. 

Digestion generally is not so active as normal, but may be more 
active. HCl. may be increased and may cause ''heartburn/' This is 
relieved by antispasmodics, e. g., K. Br. and alkalies. The stomach 
wall is congested and pours out watery secretions. 

Liver. 

According to Tarnier, 1857, there occurs a fatty infiltration of 
the lobules from around the intra-lohiilar vein. By this he explained 
the Glycosuria. This occurs in 50% of cases. Not proved. Some- 
times find multinuclear cells supposed to come from the placental 
site, and villi in the liver ; said to be one cause of eclampsia. 
(Schmorl.) 

Intestines. 

Patient is usually constipated, due to : — 

1. Laziness and general inactivity; 

2. Uterine tumor interferes with the bearing down efforts dur- 
ing defecation ; 

3. Displacement of the intestines ; 

4. Perhaps inhibition of the nerves. 

Hemorrhoids are common from the constipation and from the 
increased venous pressure below the pelvic diaphram. 

Nutrition. 

The body w^eight increases in the last three months according to 
Hecker and Gassner ; seventh month, 2,400 grams ; eighth month, 
1,690 grams; ninth month, 1,540 grams. Due to increased assimi- 
lation and a patient must gain one-thirteenth of her body weight 
during pregnancy. The increase comprises blood, fetus, etc., and 
the fatty structures. The hips round off and become broad, the 
breasts have more fat. 

This is a store of potential energy put away for conversion into 
heat and force during labor, and milk during lactation. 

If the fetus dies, the stimulus falls away and the gain in flesh 
does not occur, perhaps even loses weight. A sudden loss in weight 
in the latter months of pregnancy is perhaps due to the death of the 
fetus, and this fact may be used in the diagnosis of the death of the 
fetus. 

Nervous System. 

Women are more impressionable, sometimes melancholy, some- 
times gay, sometimes a change in the character of women occurs. 
They are often sleepy, especially after meals, and often sleep eigh- 
teen hours a day. May be one of the early symptoms of pregnancy. 
Sometimes hysterical disorders, perhaps a sort of fainting spells 



NOTES OX OBSTETRICS— JUNIOR CLASS. 53 

which alarm the friends, but are not dangerous. Examine the heart 
and investigate diet and excretions. A true psychosis may develop. 
Morally unreliable ; perception not so acute, and interpretations often 
false; therefore, careful in judging the acts of pregnant women. 
Not reliable witnesses. Often nervous and hyperexcitable. 

Nerves. 

Changes occur only in the genitals. The great cervical ganglion 
grows to twice its usual size, and the nerves of the uterus hypertro- 
phy ; no changes in the spinal cord, save an increase in the reflex 
irritability. 

Liable to numerous reflexes, through the sympathetic system, e. 
g., vomiting, indigestion, flushes. 

Neuralgias. 

Facial, toothache, sciatic pains ; headache, but perhaps this is 
due to deficient excretion. Any persistent headache must m.ake you 
think of toxemia. Sometimes disturbances of the senses, e. g., 
Hemeralopia, amaurosis, hardness of hearing, but perhaps these 
are pathological. 

Thus it is seen that pregnancy affects the whole body of the 
woman. No organ but takes part in the process. More work is 
required of every tissue, and if some part is not in good health, 
pregnancy develops this fact. ''Gestation tests the integrity of every 
structure of the body" (Barnes). Organs in the ordinary state of 
health, working to a satisfactory degree, may under the stimulus of 
pregnancy prove insufficient and even develop processes decidedly 
pathological and dangerous. The normal and pathological are thus 
brought close together and we shall see in the pathology of preg- 
nancy that pathological conditions are often only exaggerations of 
?he normal, induced by gestation. 

General Description of the Ovum at Term. 

The embryologist has followed the ovum in its development 
from the earliest period, and it is unnecessary and impossible for us 
to repeat it. The ovum at term (the end of pregnancy) presents 
for examination: (i) The placenta; (2) The cord; (3) The mem- 
branes; (4) The liquor amnii ; (5) The fetus. 

The Placenta is a cake-like organ and weighs (average of 1,492 
placentae), 501 grams.' Placentae from large children are heavier, 
from syphilitic children heavier than from healthy children of the 
same weight. The placenta is i^ to 2 c. m. thick and 15 to 18 
c. m. broad. It is irregularly round, but may assume any shape, tri- 
foliate, or double, as in some apes ; further, for example, may be 
extensive and thin, or small and thick. The tissue of the organ 



54 NOTES ON OBSTETRICS— JUNIOR CLASS. 

is dark red, soft,, friable, but woven with tough fibrous tissue and 
blood vessels. The placenta lying on the wall of the uterus, presents 
for examination the side directed to the uterus, the maternal surface, 
and the side toward the fetus, the fetal surface. The maternal sur- 
face is dark red, and close inspection will show it to be covered 
by a thin, grayish membrane which will not be peeled off, but tears 
away. The surface is broken by depressions (sulci) more or less 
deep, some with the sides adherent and showing, when separated, 
canals lined with glistening endothelium (blood sinuses). These 
sulci divide the placenta into little lobes varying from ^ to 3 
inches in breadth, called cotyledons, of which there is a varying 
number. 

The thin gray membrane covering the cotyledons is that part of 
the decidua serotina which came away with the placenta. It is 
broken here and there ; there are small pieces absent ; it is thicker 
in places and may be quite opaque (marked in cases of endometritis). 
At the rim of the placenta this decidua is quite thick (the relics 
of the closing plate of Winkler) , and by scraping into it, somewhat 
into the tissue of the placenta, one may see a large sinus, like those 
referred to, called the marginal or circular sinus, which may be 
followed all around the edge. 

The fetal surface is uneven, gray and reddish, sometimes dotted 
with whitish or yellowish areas of tough fibrous tissue. These are 
called white infarcts and are of very common occurrence. 

The cord is inserted in this surface of the placenta and the 
arteries and veins from it run over the surface of the placenta, di- 
viding and subdividing till the smallest branches disappear about 
54 inch from the edge. This surface is covered by a thin membrane, 
the amnion, which is easily stripped ofif all over except at the in- 
sertion of the cord, where it is fast. Near the insertion of the 
cord can sometimes be found (usually adhering to the amnion), a 
small yellowish vesicle, the rem.ains of the umbilical vesicle. 

Struchtre of the placenta. About the fifth week the ovum looks 
like this, covered with tiny tufts, which have grown into the decidua 



serotina and reflexa, but are only loosely attached to same. These 
tufts are called villi. Each villus consists of an inner layer derived 
from the endochorion, and an outer epithelial layer from the ex- 
ochorion ; each villus contains an artery, a plexus of capillaries and 
a vein. These vessels are developed from the vessels which the 



NOTES ON OBSTETRICS— JUNIOR CLASS. 55 

allantois brings to the periphery of the ovum about the second week. 
The first villi are simple tubes, but as the ovum grows they become 
more branched and at term are closely interwoven like trees. 

While the villi that are in contact with the decidua serotina 
multiply and grow exceedingly, those on the decidua reflexa atrophy, 
because there are no blood vessels. That part of the chorion which 
lay against the decidua reflexa and whose villi atrophied, is called 
"chorion laeve," that part which was against the serotina, and whose 
villi increased so markedly is called "chorion frondosum" (placenta). 
Some of the villi, dip deeply into the decidua and spread out a little 
like buttons, so-called anchoring villi. 

The placenta is made up of these villi closely packed together 
and thousands in number. In order to explain the structure of the 
placenta let us proceed as follows : 

The arteries from the child arriving at the placenta divide and 
subdivide into many fine twigs. From each of these twigs a "tree" 
of villi hangs. 

Imagine a thousand tiny trees grasped by their trunks, the 
branches and leaves interlacing closely. Inside the villi the blood 
circulates, in the arteries, capillaries and veins. These villi are sur- 
rounded by blood (of the mother), which is circulating in spaces 
called lacunae. These lacunae are formed thus : 

The vessels of the uterus at the placental site lose their coats 
and are developed into large passages lined with a layer of endo- 
thelium and called sinuses. These sinuses go through the decidua 
serotina, into the sulci, between the cotyledons, and from here 
open into the spaces (lacunae) into which the trees of villi dip. 

Schematically the placenta is represented thus : 



The minute structure of the villi has been much disputed. About 
the middle of pregnancy the villus consists, from without inward, of 
(i) a layer, of syncytium, (which, it is generally admitted now, 
comes from the epiblast or trophoblast) ; (2), next a layer of cells, 
or Langhan's layer, also from the epiblast; (3), the stroma of the 
villus, mesoblast; (4), the wall of the blood vessel inside the villus. 
Later in pregnancy, the syncytium thins out, the layer of Langhans 
atrophies. 

The lacunae, or intervillous spaces, are lined with maternal endo- 
thelium for onlv a short extent. If it lined all the surface of the 



56 XOTES OX OBSTETRICS— JUNIOR CLASS. 

spaces it would be found on the villi. The blood floats free around 
the syncytium, and may be said to be outside the maternal ves- 
sels. 

V^ery recent studies (by Veit and others) tend to show that 
the syncytium produces a toxin, and the tissues an anti-toxin. This 
toxin is said to have something to do in the production of eclampsia. 
An anti-syncytio-toxin serum has been prepared. (See Eclampsia.) 
No real proof as yet. 

There is no communication between the blood flowing in the 
lacunae (maternal) and the blood flowing through the villi (fetal). 
Therefore, the interchange of water, food, salts, etc., must be by 
osmosis. Solid particles, e. g., microbes, ,do not pass over unless 
there is some destruction of the walls of the villi, which they may 
cause themselves. 

Ahlfelt injected emulsionized fat into the vessels of the mother; 
none could be found in the fetus. Saenger proved that in leukemia 
of the mother, no white blood corpuscles were in the fetal circulation. 
The blood from the various lacunae is collected by large veins which 
pass through the decidua into the maternal veins. The large circu- 
lar sinus collects a great deal of blood. One can see these veins 
and sinuses on the placenta between the cotyledons. 

The placenta is well formed by the tenth week; it grows at 
the rate of loo grams a month to the seventh month; 60 grams 
in the eighth, 40 in the ninth, and 6 grams in the tenth. It is located 
generally either on the anterior or posterior surface of the uterus ; 
sometimes on the sides. More often on the right side, more often 
anteriorly. Ahlfeld, in eleven Cesarean Sections, found it nine 
times in front; Schroeder, fifty-five cases, thirty-eight times an- 
teriorly ; rarely attached to the fundus. May be inserted low in the 
uterus, and if it overlaps the internal os, we speak of placenta 
previa. Reason for these various insertions not known ; perhaps 
due to varying posture of the woman when the ovum entered the 
uterus, or condition of health of uterine mucosa. 

The separation of the placenta during labor occurs in the am- 
pullary layer of the decidua, at the expense of the mother. 

The Memhranes are continued all round the edge of the placenta. 
We distinguish an inner, transparent, thinner, tougher layer, the 
amnion, and an outer, thicker, cloudy, somewhat opaque, friable 
layer, the chorion, or chorion laeve, in distinction to the placenta, 
which is the chorion frondosum. On the maternal surface of the 
chorion, patches of more or less thick decidua are adherent. The 
two layers are easily separated; sometimes there is a jelly-like sub- 
stance between them, relics of the allantois, the jelly of Wharton. 
The chorion is never vascular, but sometimes one can see vessels in 
the decidua adherent to it. If large and heavy, they indicate endo- 
metritis. At some point there is an opening through which the fetus 



NOTES ON OBSTETRICS— JUNIOR CLASS. 57 

passed. This is usually lo c. m. from the edge of the placenta, but 
perhaps nearer if the placenta was situated low in the uterus. 

The Umhilical Cord connects the fetus with the placenta. In 
the second week a growth takes place on the lower end of the in- 
testinal tube, which goes out of the abdominal cavity, carrying 
on it two veins and two arteries coming from the primitive aorta. 
This is called the allantois. Part is constricted in the belly to form 
the bladder, the part that grows out, strikes the periphery of the 
ovum and spreads out on it. The elements of the allantois grow 
into the chorionic villi and carry into them the artery, vein and 
capillaries. 

In the human fetus the allantois forms only a small part of 
the abdominal pedicle (His). At first the amnion surrounds the 
cord, but is not attached to it. Later the liquor amnii pushes the 
amnion against the inside of the chorion. The cord therefore is the 
end stage of the abdominal pedicle. It is covered with several 
layers of epithelium, being somewhat similar to that covering the 
fetus. The cord at full term is a spirally twisted organ (usually 
from right to left), and is inserted in the belly of the fetus at the 
navel. It is 50 to 53 c. m. long, but this varies much — from 7 to 
no c. m. There may be one-fourth to several hundred twists in it. 
Cause is the movement of the child and the direction of the grov/th 
of the vessels. 

The cord may be inserted at any point in the periphery of the 
ovum, but the normal site is about the center of the placenta, and 
the insertion is brought about in this way. The allantois appears 
at the abdominal opening of the fetus as a stalked vesicle. The 
amnion about this time has closed and now the development of the 
two folds : head and caudal begins. The vessels of the allantois will, 
of course, grow most where there is the most nutrition ; therefore, 
at the placental site. The belly of the baby is usually turned to- 
ward the decidua serotina, so the vessels have a straight course 
from the baby to the placenta. Should the baby have its belly di- 
rected toward the decidua reflexa, the stalk of the allantois will 
strike there first and the vessels would insert there if the following 
did not occur. The head fold of the amnion develops usually faster 
than the tail fold. This has a tendency to swing the head around. 
The amnion, striking the stalk of the allantois, forces this around 
till the fetus lies wnth its bellv opposite the placenta. (See Ahl- 
feld). 

Should the development of the amnion folds be such that the 
stalk of the allantois is not swung around to lie on the placenta, 
the future cord is inserted at that point of the periphery of the 
ovum where the allantois is arrested. This may be away from the 
center of the placenta (eccentric implantation of the cord), at the 
edge of the placenta, (marginal insertion, sometimes called battle- 



58 NOTES ON OBSTETRICS— JUNIOR CLASS. 

dore placenta), or more or less far from the edge of the placenta, 
in the membranes, (velamentous insertion). 
The cord is made up of: 

(i) Covering of epithelium. 

(2) Two arteries and one vein (one atrophies), placed thus. 

(3) Relics of the omphalo-mesenteric duct. 

(4) Remains of the allantois. 

(5) Jelly of Wharton. 

This last binds all the structures together. If large in amount, 
we speak of a fat cord ; if small, a lean cord. 

The arteries are continuations of the hypogastric arteries ; the 
veins of the umbilical vein. The arteries are twisted around the 
vein, and they are also twisted on themselves. Vein also. As a 
result there seem to be valves in the vessels, called valvulae-Hobo- 
kenii. Arteries have a strong middle coat which has something 
to do with the arrest of hemorrhage at birth. They anastomose 
near the placenta. 

At the skin of the child is a sharp line of demarcation. A few 
capillaries from the skin go up on the cord for one-eighth of an 
inch. There are no vaso-propria, therefore, the cord must receive 
its nourishment from the blood passing in the arteries and veins. No 
nerves have ever been demonstrated in the -cord. 

The cord may form knots. False. True. 

False Knots are merely irregularities or varicosities in the course 
of the vein, e. g., surrounded with the jelly of Wharton. 

True Knots are knots of various complexity, occur once in one 
hundred and fifty cases ; may be single or double knots, tightly 
drawn or loose. Factors favoring true knots are active child and 
long cord, large amount of liquor amnii. 

Knots form during labor, often. A coil of cord lies on the 
bottom of the bag of waters, the head passes through this, or an arm 
may be slipped through and the body follow. Knots formed dur- 
ing pregnancy may cause the death of the fetus. In these cases 
there is a structural change at the point of constriction. Not so in 
those formed during labor. Must demonstrate the cord to be im- 
pervious before you can use it, as explaining the death of a fetus. 

A knot may form around a limb of fetus, but latter dies first from 
interruption of circulation before the limb is constricted. 

The Liquor Amnii 

This is the fluid by which the fetus is surrounded. It is about 
1,000 grams in amount on the average, but varies normally between 
500 grams and 2,000. Anything over 2,000 is polyhydramnios, or 
hydramnion ; below 500 is oligohydramnion. Amount diminishes to- 
ward the end of pregnancy. About the seventh month one some- 



NOTES ON OBSTETRICS— JUNIOR CLASS. 59 

times finds a great deal of liquor amnii, but this diminished later. 
Cause for this? 

It is a clear white fluid, more or less full of suspended particles 
of Vernix Caseosa, which is composed of fatty matters and cast-off 
epithelial cells, and the lanugo. It is more or less milky. E^rly 
in pregnancy it is clear. Later in pregnancy it is less so, due to the 
suspended matters, fatty, lanugo, scales. If fetus dies it gets blood 
stained from transfusion of blood pigment. If fetus becomes 
asphyxiated it becomes green, due to meconium admixture (lack of 
O stimulates intestine of fetus). Alkaline reaction. Specific gravity 
may have something to do in determining presentation and position 
of child (DeLee). Specific gravity 1006 to 1012, which diminishes 
as pregnancy goes on. 

The cryoscopic point (freezing pt.) of the liq, amnii is higher 
than that of the fetal or maternal blood. Therefore, generally speak- 
ing, the liq. amnii is destined to be absorbed. (Keim, before Paris 
Obst. Socy., in 1901.) 

Albumin is present but in varying amount ; according to Prochow- 
nick, from 0.6% to 5.2%, at the end of pregnancy. More albumin 
at the middle of pregnancy, then decreases. Has the same propor- 
tion of salts as blood serum, i. e., 0.5%, about. 

Sodium. Sulphate. 

Calcium. Phosphate. 
^,s Carbonate. 

Urea — Important Finding. 

Prochownick found an increase in the amount of urea as the 
pregnancy went on so that at term the per cent was .23%. French 
authors place it at .42%. Ahlfeld observed a case 31 days, where 
liquor amnii was being discharged, and found the amount of urea 
so small that it could not be measured. Said that there is urea in 
eggs; fetus must secrete it. (Barnes.) 

Bondi, C. f. G., 1903, page 636, found pepsin, a diastatic fer- 
ment, sometimes a fat splitting ferment and a ferment like the 
fibrin ferment in the liq. amnii. 

Sources of the Liquor Amnii. 

Quite important and interesting subject. In general there used 
to be two hypotheses, one that it is from the mother; second, from 
the fetus ; but now, recognizing that really in the beginning every- 
thing comes from the mother, these two theories have been joined, 
and it is believed that the liquor amnii comes : 

(i) Directly from the mother by transudation through the am- 
nion. 

(2) Through the fetus by way of the skin, the urine (?) and the 
fetal placenta. 



60 NOTES ON OBSTETRICS— JUNIOR CLASS. 

In favor of the first theory may be adduced : 
(i) When K. I. is given to the mother, it will reappear in the 
liquor amnii, even when the fetus is dead. (Haidlen.) 

(2) Sometimes the fetus dies and we find a large placenta with 
more liquor amnii than is normal at that period. 

(3) When mother has heart disease, or any disease attended 
with dropsies, likely to find increase in the liquor amnii. 

In favor of the theory that the liquor amnii comes, at least in 
part, as a urinary secretion from the fetus, we have : 

(i) The constant occurrence of urea in the liquor amnii. 

(2) The demonstration from pathological formations of the fetus, 
e. g., obstruction of the urethra and ureters, that the kidneys secrete 
urine. 

(3) The occurrence of urine in the bladder at birth. Ahlfeld has 
strongly opposed this view, and asserts that normally the fetus only 
exceptionally urinates into the liquor amnii, and that the liquor 
amnii is a transudate from the maternal blood vessels or through 
the skin of the fetus. Part of the 1. a. is a transudate from the fetal 
structures in the cord and placenta, as demonstrated by the poly- 
hydramnion in cases of fetal heart disease. 

The fetus drinks the liquor amnii a great deal, and it forms a 
part of his daily diet. 

Uses of the Liquor Amnii. 

1. Food. Proven by: 

(a) The finding of lanugo in the meconium has proven 

that the fetus drinks the liquor amnii. Further, real 
swallowing motions have been determined in the 
fetus. 

(b) A case of occlusion of the gullet, the fetus was atro- 

phied. 

(c) The liquor amnii contains albumin constantly, and if 

he drinks enough will get a considerable amount of 
albumin. 

2. As a water cushion preventing injury and allowing free mo- 
tions of the fetus ; this prevents deformities, e. g., club foot. 

3. Prevents the amnion from aahering to the fetus and causing 
deformities, e. g., hare lip, hemicephalus, amputations, imperfect 
closures of the body cavities ; all arrests of development due to 
strands of amnion. Amniotic bands cause a large number of congeni- 
tal deformities called Simon art's bands. 

4. During labor it helps dilate the passages by forming a fluid 
wedge with the membranes; (2) washes out the vagina for the pas- 
sage of the child, and (3), surrounding the fetus completely, it dis- 
tributes, (as all fluids do), the compression exerted by the contract- 
ing uterus, equally in all directions, and thus saves any part of the 



NOTES OX OBSTETRICS— JUNIOR CLASS. 61 

fetus from injurious pressure. When the hquor amnii has been 
discharged, the fetus is exposed to this pressure, and if it is long 
continued, may succumb from it. Extreme moulding of the fetus 
m.ay result from an empty uterus. 

The fetus increases in specific gravity toward the end of preg- 
nancy, especially its head, whereas the specific gravity of the liquor 
amnii decreases. This has a tendency to allow the head to sink, and 
a favorable vertex position produced. Recently Schatz (C. F. 
G., oo-oi), denies this, saying breech is heavier end. 

The Fetus at Term. 

lies folded together in the uterus with all the joints flexed, so that 
it occupies very little space. Head flexed on chest, chin touches 
sternum, arms folded on chest, thighs on abdomen, legs on thighs. 
The umbilical cord passes out from the belly to the w^all of the 
uterus, its coils usually lying in the hollow made by the juxtaposition 
of the extremities. The back is sharply curved, like the letter C, 
and lies applied to the uterine wall. The length of the fetus in this 
position is about 50 c. m. and it weighs about 3,200 grams. 

Signs of Maturity. 

(a) Length 50 c. m. about; some babies short and broad, others 
long and thin. 

(b) Weight 3,200 grams, but this is fallacious, as a fetus may 
be mature, yet small and thin. Boys heavier than girls. 

(c) Hair is well developed, perhaps 3 c. m. long. Lanugo al- 
most gone. Some children are almost bald at term. Others, prema- 
ture, have long hair. 

(d) Nails protrude beyond the fingers and to the ends of the 
toes. It is said (Negri, Ann., de Obstet., June, 1885), that if the 
foot is 8 c. m. long, baby weighs 3,500 grams. 

(e) Panniculus Adiposus well developed. Premature infants are 
thin and look like old people, having thin skin and wrinkled. 

(f) Cartilage in ear well developed; therefore, ear is elastic and 
stands out well from the head. 

(g) Navel is at the middle of the belly (from symphysis to 
ensiform), two or three c. m. below middle of body, higher in girls 
than boys. 

(h) Testicles are both descended. In girls, labia majora almost 
always cover the minora. 

(i) Vernix Caseosa well developed ; varies. 

(j) Color of the skin; white or pink means maturity, red occurs 
in prematurity. 

(k) The milia and comedones around the nose have usually dis- 
appeared. 



62 NOTES ON OBSTETRICS— JUNIOR CLASS. 

(1) The osseous center of the lower end of the femur is 7 to 
8 m. m. broad. 

(m) Manifestations of Hfe: 

1. Voice: loud, ripe, whimpering, in early born. 

2. Sucking movements strong, weak in early born. 

3. Passage of meconium, early and frequent in mature chil- 

dren ; late in premature. 

But not one of these signs is absolute. The best is the length 
of fetus. Seldom in a position to say that a given fetus is prema- 
ture ; can only say that there is a high degree of probability. 

If the fetus presents the signs of maturity w^ell marked, ^can say 
that it is mature, but cannot say that it is the result of a 9-months' 
pregnancy, as a mature child can be born at 8 months. (See 
Parvin.) 

The size and development of the placenta and cord are unre- 
liable, as indices of maturity of the fetus. If the decidua bordering 
on the placenta is vascular, may be premature, if endometritis can 
be shut out. 

Ahlfeld found scratch marks on the inside of the amnion, made 
by the fetus after the nails had grown beyond the finger-tips. 

The evidence of life on the part of the fetus forms an interest- 
ing and instructive study. Aside from the fetal heart sounds, the 
direct palpation of the heart through the abdominal walls, the fetal 
or umbilical souffle, all things which will be considered at length 
later, there are palpable and audible evidences of life. 

The fetal movements are the longest known. One can distinctly 
see the extremities move acress the uterine wall, and there are stretch- 
ing movments. These may be jerking or distinct kicks. Then the 
fetus often stretches out, the mother appreciating this as a sort of 
knock of the breech against the fundus. 

Hiccough has frequently been diagnosed. They are short, pe- 
riodic, two or four seconds apart, jerking motions of the shoulders 
or breech, attended with a visible and audible thump against the 
abdominal wall. They resemble hiccough in evcrv'thing except noise; 
and in one case I observed the hiccough before delivery and after 
the delivery, inside of a minute, the child was hiccoughing audibly. 
Have been observed by the writer as early as the 5th month. ]\Iay 
make the diagnosis of pregnancy. 

Respiratory movements of the chest of the fetus can, in favorable 
cases, be seen by observing carefully the navel region of the mother. 
These movements are not deep enough to bring the liquor amnii into 
the lungs, but serve to develop the chest and chest muscles ; they 
are 60 to 70 in the minute. If you can observe a child that has been 
just delivered, you will notice before the gasp, which fills the lungs 
with air, these tiny respiratory movements ; and in children that 



NOTES ON OBSTETRICS— JUNIOR CLASS. 63 

have been deeply asphyxiated, the return to Hfe is evidenced by the 
beginning- of these faint respiratory movements. 

Babies certainly swallow in utero, as was said before, but no one 
has diagnosed the movement. And they suck their thumbs some- 
times, as one often sees a new-born child put his thumb in the mouth ; 
in one case reported, the thumb was swollen from sucking. Babies 
presenting the face in delivery will suck the finger of the examining 
hand. 

The Physiology of the Fetus. 

For our purpose, this study is useful only after the fifth month. 
The changes from the vitelline circulation to the omphalomesenteric, 
tlie introduction of the allantoic circulation at the second week, and 
the final disappearance of the omphalomesenteric circulation about 
the fifth week, upon the establishment of the placental circulation, 
need only to be mentioned. They were learned in embryology. 

Blood. 

Has about the same appearance as maternal blood, but has less 
fibrin and hemoglobin. Red blood cells are more easily decom- 
posed. More reds in boys than girls. Find nucleated reds up to 
the ninth month, after birth rarely find one. White blood cells 
more than the mother. Umbilical vein has more than arteries, there- 
fore, since none can pass over from the mother, the placenta must 
be a place where white blood cells are made. Hemolysine has been 
found in fetal blood. 3'iunch. Med. Woch., 02, No. 12. No dias- 
tatic ferment. (Bial Pflugers, Archiv., No. 53.) 

Total quantity of salts, about the same as maternal. 

(See C. F. G., 1895, No. 45. London Obst. Soc. Rep.) 

(See Limbeck on the Blood.) 

The alterations in the fetal blood explain the following condi- 
tions : 

1. Icterus neonatorum. 

2. The tendency to'^bemorrhages from all sources. 

3. The liability to septic infection. 

Circulation. 

The hypogastric arteries branch off from the common iliacs and 
pass through the navel in the cord to the placenta. They carry part 
of the blood in the fetus to the villi in the placenta, and here it 
passes through the capillary network. Right alongside of it is the 
arterial blood of the mother circulating in the lacunae or intervillous 
spaces. The blood from the arteries is quite venous in character, 
but becomes oxygenated by the oxygen passing over from the ma- 



64 NOTES ON OBSTETRICS— JUNIOR CLASS. 

tenial blood. The blood is then returned to the fetus through the 
umbilical vein and distributed, as you learned in anatomy and physi- 
ology. 

The placenta is, therefore, the organ for the oxygenation of the 
blood; in other words, it is the respiratory organ of the fetus, and 
this is so, because: 

1. If it becomes detached the fetus dies of asphyxia. The fetus 
makes respiratory movements and gets liquor amnii in its lungs, 
really drowns. Same occurs if umbilical cord is compressed. 

2. Zweifel has seen in certain mammalia (dog, mare), the ar- 
teries with venous blood and the vein with , arterial blood. 

The fetus needs very little oxygen, as its combustion processes 
are very slow, it moves little and meets with no resistances ; it has 
no perspiration and evaporation from the skin ; very little digestion. 
It loses no heat. Since this is so, the fetus tolerates withdrawal of 
its oxygen supply for a time very well, i. p.., asphyxia. As preg- 
nancy goes on this toleration is lost. It is believed the fetal blood is 
more and more venous as pregnancy goes on. The process by which 
the fetal blood carried to the placenta, becomes oxygenated is prob- 
ably analogous to the process going on in the lungs. 

The placenta has other functions (Respiration, I). 

II. It provides food for the fetus, especially water. All sub- 
stances in solution which do not destroy the integrity of the maternal 
blood, pass on to the fetus through the membrane, separating fetal 
and maternal blood, e. g., salts, K. L, salicylic acid, etc. Gases pass 
over, e. g., chloroform, and CO, ; therefore, the danger of giving too 
much ChCl3. Ahlfeld found the liquor amnii in many cases of 
Cesarean Section, stained with meconium. It is bad for pregnant 
women to go to large gatherings, or where large coal stoves are used, 
as the CO may injure the fetus. 

III. It receives the products of decomposition of the fetus and 
the maternal blood carries them away to the excretories. 

IV. Placenta has the function of storing Glycogen (See R, D. 
& LeP., page 103). 

V. Believed that the chorionic villi have some peptonising power 
which changes albuminoids into peptones, and thus makes them dif- 
fusible through the membrane separating the fetal from the ma- 
ternal blood. 

VI. The placenta offers a mechanical barrier to the passage of 
germs. Only so, however, if placenta is intact. Recent investiga- 
tions tend to disprove this. 

Bar & Renon. Rev. Mens des mal. de I'enfance, Nov., 1895, found 
the blood of the umbilical vein in two cases of tuberculosis of the 
mother, fatal to guinea pigs. 

Freund & Levy, Berl., Klin. Wochenschrift, 1895, No. 25 (ref. in 
above), found the typhoid bacillus in the blood of the fetus in a case 



NOTES ON OBSTETRICS— JUNIOR CLASS, 65 

of typhoid. Still, there may have been lesions of the boundary wall, 
I. e., the covering of the villi, caused by the bacilli themselves. 

If the bacteria do not pass, the toxines do, and may produce 
lesions in the fetus. 

The child has its own metabolism, but it gets its nourishment 
in a condition ready for immediate assimilation. There is great ex- 
cess of accretion over excretion, as very little matter is found in the 
intestines and the skin and kidneys are inactive. The temperature 
of the fetus is ^2 degree C. higher than the mother. This is proven 
in breech cases. 

Nutrition of the Fetus. 

1. From the blood in placenta. 

2. From the liquor amnii. 

The liver is active, — demonstrated by the presence of bile in the 
meconium. The meconium is a tarry, greenish-black substance, 
found in the colon of the fetus in considerable quantity even before 
the seventh month. It accumulates in the colon and, therefore, there 
is peristalsis of the intestines, which has also been demonstrated ex- 
perimentally. The meconium becomes thicker in the latter weeks as 
the intestine is absorbtive. Aleconium is composed of secretions of 
the intestinal canal, the solid particles swallowed with the liquor 
amnii, lanugo, epithelium, vernix caseosa and bile. Chemically, 
cholestearin, bilirubin, fat and mucin. 

The stomach. There is a little pepsin and milk curdling fer- 
ment, from the fifth month on. 

The Kidneys. These are active from the early months, as Nagel 
has shown. The liquor amnii is partly urine, though this is dis- 
puted by Ahlfeld. He says the excrementitious matters which the 
kidney usually excretes are taken away through the placenta. Still, 
urea has been found in the liquor amnii, the bladder has been found 
distended, even so as to be a hindrance to labor, the kidneys are 
there, and, by analogy with other organs, must zuork. Urine is 
often found in the bladder of new-born children. They sometimes 
urinate freely during delivery. 

We know little regarding the assimilation of the fetus. Water, 
salts and diffusible albuminoids are absorbed from the placenta. W^e 
do not know how the fetus gets fat, unless it makes it from the 
albuminoids. .Until the second month, the fetus is almost all water, 
has more water even than milk. At the end of pregnancy the fetus 
is 74% water. 

The Growth of the Child. 

It is important to know how a fetus grows, especially to be 
able to determine if a given pregnancy can safely be interrupted. 
The size of the child is then determined by examining it from the 
outside. The length of the child gives us the safest guide. 



66 



NOTES ON OBSTETRICS— JUNIOR CLASS. 



TABLE. 



4 weeks (head to sacrum) 0.8 

8 
12 
16 
20 
24 
28 
32 
34 
36 
38 
40 





Weight 


c. m. 


grams , 


0.8 




2.5 




8.0 


35 


16.0 


41 


23.0 


222 


36.3 


1 142 


40.4 


1635 


45-1 


2107 


48.3 


2424 


49-9 


2806 


50.5 


3016 




3168 



A simple rule to determine the length of a fetus at the several 
months of gestation, is this : square the number of the month which 
will give the length in c. m. of the fetus. After the 5th month add 
5 c. m. for each month. 

For example, at 3 months the fetus is 9 c. m. long. 

at 5 months the fetus is 25 c. m. long. 

at 6 months the fetus is 30 c. m. long, 25 -[-5. 

at 7 months the fetus is 35 c. m. long, 254-5+55 ^tc. 

Both length and weight of children vary. Some babies grow 
faster than others. Some at term or over are small and puny, which 
may be due to general poor constitution of mother, or her poor 
development. Women with generally contracted pelvis (indicating 
j^ arrested development), have usually small babies. (See LaTorre.) 
Large muscular women have large babies, same true if father is large 
and strong. Fat women have more often small babies. Good nour- 
ishment or poor has a little to do with the development of the 
child. People of better classes have slightly larger infants than 
the needy poor. Therapeutically, we try to influence the growth of 
the child by regulating the mother's diet (more later). White chil- 
dren are larger than negro children. Children of different preg- 
nancies vary in size., As a rule, they get larger after the first. 
One observer said the second child smaller than the first, then they 
are larger successively. After the seventh or eight child, they de- 
crease in size. This is due to the shorter length of later pregnancies, 
or perhaps nutrition not so good. The reason for the progressive 
increase in size, — perhaps larger placenta. Girls are smaller than 
boys — 3 or 4 oz. 

If child is carried over term, it overgrows, or its head gets 
harder — shoulders broaden. These changes not invariable. If pla- 



NOTES ON OBSTETRICS— JUNIOR CLASS, 67 

centa is diseased or unusually small — child is small, e. g., syphilis, 
nephritis, endometritis, infarcts. General health of mother some- 
times has an effect on the size of the child. Occasionally find cranio- 
tabes. 



DIAGNOSIS OF PREGXAXCY. 

A certain diagnosis is not always possible. A high degree of 
probability can always be reached. Mistakes without number have 
occurred, and by good men, also; almost always the result of care- 
lessness or of prejudgment. Greatest difficulty in the first four 
months, but sometimes throughout pregnancy. Socrates said, in 
studying ourselves we must "Lay aside prejudice, passion and 
sloth,'' and let this be your motto in making a diagnosis of preg- 
nancy. Sometimes the signs are so apparent that a diagnosis can be 
made at a glance, but occasionally you will be mistaken even here, 
and the laity w^ho think that a diagnosis in this matter is always 
easy, will lose faith in the doctor. In uncomplicated cases, i. e., 
where it simply rested to determine whether pregnancy did or did 
not exist, oftener pregnancy diagnosed where it did not exist, than 
was an existing pregnancy not recognized. 

When the diagnosis was to differentiate some pathological con- 
dition simulating pregnancy, from a pregnancy, the pregnancy was 
oftener missed. A great many different conditions can simulate 
pregnancy, and the effects of a mistake are often disastrous to the 
patient, either physically or socially. (See Montgomery.) 

Sources of Error. 

1. In the early months there is no absolute sign of pregnancy. 

2. In later months the only absolute sign is the fetal heart tones, 
and these may be not audible at time of examination, or fetus may be 
dead. 

3. On the part of the mother various hindrances may be pres- 
ent. 

(a) A very fat woman, or ascites or ovarian tumor or fibroid. 

(b) A rigid abdominal wall and vagina, natural or voluntary 

and intentional. 

(c) False statements : 

1. Intention to deceive: Wants you to pass sound for 

diagnostic purposes : Girl unmarried, tries to hide 
it from friends, 

2. Self-deception : Sometimes woman so desirous for 

a child that she imagines a pregnancy — "pseudcye- 
sis." Women have even gone in labor, imagining 
themselves pregnant, and having pains. 



NOIES ON OBSTETRICS— JUNIOR CLASS. 69 

Signs are divided into (i) Subjective and (2) Objective. 

Subjective, those that the patient tells us, sometimes called Ra- 
tional. 

Objective, those that we feel, see, hear, — sometimes called 
Sensible. 

First have but little value because of above reasons, and are 
at best presumptive. The latter are to be given more credence, and 
are probable or certain. This is another division of the signs. 

Presumptive ; Probable; Certain. 

For the purposes of study, wq W\\\ divide the pregnancy into 
three periods of three months each, i. e., three trimesters. 

Signs of the first trimester: Subjective. 

I. Cessation of Menstruation — Important, but must answer cer- 
tain qualifications : 

(a) In a woman previously regular. 

(b) No pathological cause for amenorrhea. 

(c) Must persist as long as the pregnancy lasts. Value of 

sign increases as pregnancy advances. 

(d) Nothing pathological must result from it. 

Still, certain fallacies likely to occur, since a pregnancy can oc- 
cur in the absence of menstruation, e. g., (A). 

1. Before menstruation in a girl. ''Fruit before flowers." 

2. During the amenorrhea of lactation. 

3. After menstruation has ceased, menopause. 

(B) Pregnancy may be accompanied by one or two menses. 
Sometimes when the conception took place shortly before a period, 
there may be a few drops of blood during the period. The next 
period is absent. Still one regular period may occur. Cases where 
menstruation has persisted during pregnancy are not authentic. 
They can be almost always ascribed to some pathological condition 
of the uterus. Some women claim that they menstruate throughout 
pregnancy. When nothing pathological results from this and no 
other cause for the flow exists, (if there is a flow), which is not al- 
ways so, even if the woman asserts it, it may be menstrual. Per- 
sonally, I do not believe a normal uterus menstruates after the sec- 
ond month of pregnancy. Better to consider them pathological. 
The pathological conditions which can cause a flow during preg- 
nancy are : 

(a) Rupture of. a varix, at any point of the cervico-vaginal- 

vulvar canal. 

(b) Diseases of the endometrium (which is not obliterated 

till fourth month), as endometritis, which is not rare 
in pregnancy. 

(c) Cervical erosions. 



70 XOTES OX OBSTETRICS— JUNIOR CLASS. 

(d) Uterine polyp. 

(e) Diseases of the ovum; placenta previa; myxomatous de- 

generation of chorion ; chronic abortion. 

(f) Extra uterine pregnancy. 

(C) Other conditions can cause cessation of menses: 

1. Change of climate, return from a sea voyage (noticed 

in girls coming from Europe) . Seldom persists over 
three months. 

2. Mental effects. A girl who has exposed herself to 

conception may have a cessation of menstruation 
and not be pregnant, from actual fear. 

3. Pathological conditions. 

(i) SyphiHs ; (2) Tuberculosis; (3) Anemia or sec- 
ondary anemias from tuberculosis, etc. 

4. Sometimes women are irregular, often being amenor- 

rheic for several months without apparent cause. 
During lactation menses often are irregular. There 
are sometimes long intervals. True, also, at the ap- 
proach of the menopause. 
You are safe in regarding a woman who is menstruating regular- 
ly as not pregnant. (Schroeder.) As a general rule, the sudden 
cessation of menstruation in a woman who can conceive is a fairly 
sure sign of conception. Cessation of menstruation, then, is only 
a presumptive sign of pregnancy. It is valuable, however, in fix- 
ing the date of conception, so as to determine the time of labor, and 
must always be noted for this purpose. 

II. The morning Vomiting or Sickness. 

This begins usually after the fourth week, but may show itself 
earlier — case quoted from Montgomery, where, at the end of the 
week after marriage, patient felt squeamish. If the .i^usea is limited 
to a certain period of the day, mostly the morning, is not attended 
with symptoms of disease, comes on in a woman who can conceive 
and who previously was well, it is highly presumptive. Good to re- 
member this point in the differential diagnosis of all indigestions, in 
young women. Together with cessation of the menses, is very pre- 
sumptive, but not certain. Vomiting occurs earlier in primiparae 
and more constantly in them. IMultiparae, later and less severe. I\Iay 
be absent in both, especially so with people of the lower classes. 
Sign is of value, as it makes the diagnosis of the life of the fetus 
probable. In cases of pathological conditions complicating preg- 
nancy, it is quite useful. 

III. Symptoms of a sympathetic or reflex nature. 

(a) Salivation. Begins about the fourth week. Called "Cotton 
spitting," by Dr. Dewees. When sudden in its onset, unattended 
with fetor ex ore or other sign of mercurialism, is of some value. 
Pinard describes a mild gingivitis that may occur during pregnancy, 



NOTES ON OBSTETRICS— JUNIOR CLASS. 1l 

and may even become pathological, with loosening of the teeth, 
hemorrhage from the gums, but usually does not do so. (See Par- 
vin, 1895.) 

(b) Ringing in the ears, neuralgias. 

(c) Change in the disposition, feeling of being pregnant, etc. 
These are all unreliable, especially the latter two, since they occur 
in women not pregnant, and may be marked, especially when the 
woman believes herself to be pregnant and wants a child. Still, when 
a multipara has missed a period and says she feels that she is preg- 
nant, it is I highly presumptive (but not certain). 

IV. Irritability of the bladder, not due to weight of uterus on 
it, but to stretching of base of bladder, due to a marked antever- 
sion of uterus. Uterus same specific gravity as intestines, therefore 
can't press on bladder. May be marked in the first few months, then 
when the uterus goes up into the abdomen ceases, late in pregnancy 
begins again. No value at all in diagnosis. 

Objective Signs. First Trimester. 

A. Thoracic Genitalia, the breasts. B. Pelvic Genitalia, uterus, 
vagina, vulva, connective tissue. 

I. Mammary Glands. As early as the fourth week there may 
be tingling in the breasts and enlargement; at the twelfth week, a 
little colostrum can be pressed out from numerous fine orifices. 

Sebaceous glands increase in activity and the epithelial scales 
can be scraped off, branny scales. This is sebaceous secretion which 
hardens on the skin. Pigmentation begins in the primary areola ; 
later the secondary areola forms and is valuable in diagnosis. In 
brunettes the areola may be almost black. Secondary areola re- 
sembles dusty paper on which water has been sprinkled. 

Nipple more lerectile, enlarged, more sensitive. 

Primary areola is enlarged, becomes puffy. Said can feel milk 
ducts radiating from the nipple. 

The glands of Montgomery develop and can feel and see them 
as hard nodules. By many they are regarded as milk glands (ac- 
cessory) ; said that sometimes can trace canal connecting with the 
sinus lactiferus. Of interest in that they may become atria of infec- 
tion during pregnancy, and lying-in period. A milky secretion may 
often be pressed out in a fine stream. The glands increase in size 
from periphery to center. Growth may cease at the fourth or fifth 
month, but takes on a renewed activity toward the end of preg- 
nancy. In old primiparae the activity may not occur at all, or not 
till the second week of the puerperium. (Rare.) 

Linea albicantes (i. e., striae gravidarum), sometimes develop 
near the periphery, and blue veins may be seen coursing under the 
skin. Most important of these points are, puffiness and pigmenta- 
tion of the primary areola, and colostrum. 



72 NOTES ON OBSTETRICS— JUNIOR CLASS. 

These signs are more marked in a primipara. Of very little sig- 
nificance in a multipara, because, first, they are not so marked; 
second, traces from, the previous pregnancy remain; third, in multi- 
para often between pregnancies there may be colostrum in the 
breasts. Signs least marked in an old multipara. Aside from these 
fallacies, we must observe : 

1. Some women, especially nervous women, have pain, tingling 
and enlargement of the breasts during menstruation. 

2. May have these breast changes with pathological conditions 
of the genitalia, e. g., ovarian cyst, hematometra, fibroids (reflex 
symptoms referred to the breast). 

The enlargement of the sebaceous glands, named after him, was 
considered by Montgomery decisive, but this sign is not infallible. 

John Hunter attached significance to the sign also. Nor is the 
secretion of milk decisive. Baudelocque tells of a girl who, at eight 
years, suckled her own baby, and in Africa, with certain tribes, 
young girls suckle children, the glands being stimulated by drugs and 
friction (Tanner). Men have nursed children. 

3. Prostitutes may have a secretion of colostrum. 

4. Masturbation may cause changes in the breasts similar to those 
of pregnancy. The sign, therefore, has only presumptive value, but 
toward the fifth month the changes may be so marked as to make 
the diagnosis highly probable, but then we have better signs. 

May serve to draw our attention to the possible existence of a 
pregnancy. During lactation a sudden diminution of the quality 
and quantity of the milk is strongly presumptive of a new pregnancy. 
This shows itself in the nutrition of the baby also. 

B. PELVIC SIGNS. 

II. Discoloration of the vulva, vestibule, and vagina, and soften- 
ing of the vagina. The vulva becomes softer — darker in color. 
Vagina soft and thick and dark blue in color, sometimes violet. 
Change most marked just below the meatus urinarius and then on 
the anterior vaginal wall. The vestibule is a little prominent, and 
the meatus somewhat pouting. Due to increase in the venous cir- 
culation and congestion of the growing uterus. The vagina is 
softened early and is an important sign. Begins in primiparae as 
early as the sixth week; almost always present at the tenth week, 
but still may be but slightly marked at the eighth month. This 
discoloration and softening of the vagina varies much. 

Sometimes even at term the vaginal outlet presents a pink color, 
in other women it may be deep purple. All grades' between. In 
multiparae sign is more constant, and may be seen as early as the 
third week. The softening is almost always present, but in rare 
instances it is slightly marked even up to the fifth month. After 
this some softening always exists. 



NOTES ON OBSTETRICS— JUNIOR CLASS. 73 

Fallacies. 

1. May develop very late. 

2. May occur with anything that causes pelvic congestion. 

(a) Rapidly growing tumors (pelvic) of all kinds. 

(b) Displacement of the uterus. 

(c) Inflammation in the pelvis (causing chronic congestion). 

(d) In multiparae the vagina remains softer than normal be- 

tween pregnancies, if they follow each other quickly. 

Sign is useful in fat women and can almost always be elicited. 
Of presumptive value only. The softening is of more value. 

III. The Leiicorrhea. This begins often as early as the first 
period missed, and may continue all through the pregnancy. Al- 
most every case has leucorrhea toward the end of pregnancy. It 
may be marked — even pathological, but here some previous disease 
must have existed. Has no diagnostic importance. The symptom 
may bring the patient to the doctor, i. e., she complains only of leu- 
corrhea. i\ tough mucus plug in the cervix is also of diagnostic 
significance. 

IV". Softening of the Vaginal Portion of the Cervix. Due to 
same causes as the softening of vagina, i. e., congestive hyperemia 
of the pelvic vessels due to the activity of the growing ovum. Soften- 
ing begins from below and goes upward, and in primiparae may be 
felt as early as the sixth week. In multiparae as early as the fifth 
week. Some change always by the twelfth week. 

The lower third, softened at twelve weeks. 

The upper third, softened at eighteen weeks. 

The middle third, softened at twenty weeks. 

General comparison of Goodell : 

'Tf the cervix feels as hard as the cartilage of the nose, no 
pregnancy ; but if the cervix feels like the lip, pregnancv pos- 
sible." 

Fallacies. 

Same as those simulating the softening and discoloration of 
vagina, i. e., all conditions which produce pelvic congestion, e. g., 
rapidly growing tumors, inflammations. 

Further, in chronic endocervicitis, and chronic cervicitis, the cer- 
vix may be so hard that the softening during pregnancy is inconsid- 
erable. Value is only probable, not certain. 

V. Hegar's Sign, or softening and compressibility of the lower 
uterine segment. 

Elicited by passing two fingers in the anterior fornix and by 
bringing the external hand down on them through the lower uter- 
ine segment, or the finger may be put into the rectum, and the 
thumb in the vagina, under ether. First method best; the finger 
inside seems to meet the hand outside with just a little uterine tissue 



74 XOTES ON OBSTETRICS— JUNIOR CLASS. 

between them. The body of the uterus is soft, the cervix in its 
upper portion still hard, but the lower uterine segment is the softest ; 
sometimes may be compressed to the thinness of paper. This is due 
to the irregular grow^th of the uterus. Occurs as early as the sixth 
week in multipara — occurs at the eighth week in primipara. 

Is quite diagnostic of pregnancy but not certain. One of the 
most reliable signs of the first trimester. May be simulated by retro- 
flexions of the uterus or congestion, may be simulated by a small 
fibroma in the wall of the uterus. It may be slightly marked, or 
even absent, and because of fat or rigidity of the abdomen, may be 
hard to elicit. It may persist for a variable period after an abortion 
or a labor, even months. Danger of abortion, according to Parvin, 
if compression too great. Have felt it under many conditions of the 
non-pregnant state. 

VI. Changes in the Form, Size, Consistency and Position of the 
Uterus. 

(a) Form. The virgin form of the uterus is like a thin pear. 
When the ovum first develops, the body increases in its anterior — 
posterior diameter. Later the sides round out and then the uterus 
is spherical. Can feel the bulging above the cervix from the vagina 
— finger in each fornix. Sometimes one-half of the uterus will de- 
velop ; sometimes a groove may be felt around the ovum. 

These changes were considered already. (See physiology of 
pregnancy.) 

(b) Size. Uterus is 2^ inches long, ^ inch thick and i^ 
inches in width. Body enlarges to size of a big fist at the end of 
the third month, or better, size of a fetal head. 

The regularity of the growth is important. In doubtful cases 
examine ever}' two weeks, and one can determine a certain increase 
in size. This needs large experience, but is positive, as the same 
rate of growth is shown by no other tumor. If the uterus, instead 
of increasing in size, should remain stationary, or even decrease, 
the ovum is dead. Sometimes the uterus may increase rapidly in 
size, and go back again. Peculiar phenomenon and needs study. 

(c) Consistency. Soft, elastic, spongy, characterize the preg- 
nant uterus. Often at one point can feel a harder resistance, due 
to the ovum. Over this sometimes a groove, the vacant space be- 
tween the decidua reflexa and vera. Only palpable under especially 
good conditions, e. g., relaxed vagina and thin abdominal walls, 
docile patient. 

This softness is simulated by no tumor, except a soft myoma, 
which is very rare, and possibly hematometra. Often, even as early 
as the third month, one feels the uterus get harder (contraction), and 
an acute observer may feel the uterus harden in spots, under his 
finger (partial contractions). These findings are very important, 
but hard to elicit. 



NOTES ON OBSTETRICS— JUNIOR CLASS. 75 

(d) Position. Uterus is strongly anteverted owing to its weight; 
it falls on the bladder. Feels like a lump of dough lying flat on the 
finger. 

These four conditions, taken together, form a very probable sign 
of pregnancy in the first three months. 

In the first trimester, there are no positive signs of pregnancy, 
but by combining all, one can arrive at a high degree of probability. 

Examine systematically in the way I have laid down and care- 
fully, not being satisfied with eliciting one or two signs. Bowels 
empty, bladder empty, not too near a meal, as the full stomach in- 
terferes with palpation. Lay aside all constriction of the abdomen. 
Patient should be on a rather high table. Often have to make the 
examination w^hen patient is in bed; undesirable, but if necessary, 
put a small pillow under head, patient in oblique position, i. e., one 
foot in bed, one on a chair (for internal examination). Disinfect 
the hands carefully, first, because you may infect the woman; sec- 
ond, to get the habit of obstetric cleanliness. 

Notice the signs in order as given, because it makes a bad im- 
pression on the patient to put her back on the table because you have 
forgotten something, and further, by pursuing a system you will 
not forget anything. When some of the pathological conditions men- 
tioned in the lecture complicate a beginning pregnancy, the difficulty 
is really great and a good many diagnosticians have been foiled. The 
diffijculty in arriving at the diagnosis should warn you to careful- 
ness. Leave the diagnosis doubtful rather than be influenced to 
announce a probable condition as certain. 

If the woman asks an opinion of you, you may lean in the di- 
rection of her desires. If she is anxious to have a child, tell her 
that it is very possible she is pregnant and she should consider 
herself so till she comes again in a month, when a positive diagnosis 
can be made. If she does not desire a child, tell her it is possible 
that she may not be pregnant ; that she should not give herself any 
concern about it, but return in a month, w^hen you can tell her cer- 
tainly. This exhibition of tact is justifiable and will retain the con- 
fidence of the patient, and not interfere wath her condition. 

Under no circumstances prescribe any medicine as a placebo to 
satisfy her desire for an abortifacient. 

REVIEW OF S^IGNS OF FIRST TRIMESTER. 

I. Subjective or Rational. 

(a) Cessation of menses, presumptive. 

(b) Morning Sickness, presumptive. 

(c) Reflex symptoms — feeling pregnancy, salivation, neu- 

ralgias, presumptive. 

(d) Irritability of the bladder. 



76 NOTES ON OBSTETRICS— JUNIOR CLASS. 

1 1. Objective, or Sensible. 

(a) Changes in the breasts, presumptive. 

(b) Discoloration and swelhng of the vagina, vulva, pre- 

sumptive. 

(c) Leucorrhea, presumptive. 

(d) Softening of vaginal portion of cervix, probable. 

(e) Hegar's sign, if marked, probable. 

(f) Changes in form, size, consistency and position of the 

uterus, highly probable. 

(g) Determination of a regular rate of growth is positive, 

but requires several examinations. 

Diagnosis of Pregnancy, Second Trimester. 

The Second Trimester is marked usually by a subsidence of 
the sympathetic signs (e. g., vomiting, salivation), and an increase 
of the mechanical, while new signs make their appearance. 

Menstruation continues absent. One new subjective sign appears, 
i. e., active fetal movements. 

About the sixteenth to the eightenth week the woman begins 
to feel something in the abdomen entirely unlike any previous sen- 
sation. It takes her a week usually to determine what it is, and 
finally she concludes it is the movement of the child within her. 
She is usually beset with various emotions, especially if this be her 
nature, and she immediately feels the full glory of maternity. 

Now she is ''quick with child." It is called "quickening," and 
law now recognizes the woman as pregnant. All fears she may have 
entertained about her pregnancy vanish ; she looks forward hopefully 
to her labor, when she can be a real mother. There is a certain 
maternal instinct which serves, among other things, to propagate 
the race, but is not very long-lived ; because, after having satisfied 
the longing for offspring once or twice, the woman usually wishes 
no more. A certain German philosopher calls it egotism, saying it 
is quickly satisfied, and after that the men and women refuse to be 
"population machines." 

In multiparae the movements may be recognized as early as the 
fifteenth week. Primiparae, later ; as they do not know what the 
phenomenon is. Have been likened to the movement of a little 
bird fluttering in the closed hand ; the movements undoubtedly be- 
gin much earlier than they are felt, which is owing to their feeble- 
ness. 

About this time, also, the uterus comes to lie on the abdominal 
wall, and thus the sensations are better transmitted. They are 
weak at first but later stronger, and may in certain cases be so 
severe as to keep the patient aw^ake. As this is felt by the woman 
the sign is only of presumptive value, as it may be simulated by 
peristaltic movements of the intestine, by contractions of the recti 



NOTES ON OBSTETRICS— JUNIOR CLASS. 77 

muscles, by a tumor in the abdomen falling from one side to the 
other, or from nothing at all, — the woman simply imagines the 
sensation. 

B. Hicks believes that there is some relation between the aeration 
of the blood in the maternal sinuses, the movements of the fetus and 
the intermittent uterine contractions, a? follows : 

The circulation stagnates, CO'2 accumulates in the fetal blood, 
the child kicks, strikes the wall of the uterus, this causes a uterine 
contraction and the blood is squeezed out of the uterus ; uterus re- 
laxes, new blood flows in. Supported by the fact that in mtrauterine 
asphyxia the child makes many movements, e. g., when ergot is 
given (this causes a prolonged uterine contraction). 

The movements are felt most on changing the position, when 
the woman wakes up in the morning. Hunger causes an increase 
in the movements. Chloroform a decrease. It is certain that the 
baby has periods of activity and periods of rest, though we have 
little proof of them. Some women can tell when the baby wakes 
up, as he "stretches himself," so the women say. The movements 
are due to the stretching motions of the back and flexing and ex- 
tending the extremities. 

Sign is useful in determining the date of confinement, and get 
date of labor. Have the woman note its occurrence, reckon ahead 
twenty-three weeks for a primipara and twenty-four weeks for a 
multipara. It acts as a check on the date of last menses. 

The Objective Signs of the Second Trimester. 

These are highly important. Whereas the diagnosis in the first 
twelve weeks was only a probable one, you are now usually able 
to assert positively whether the woman is or is not pregnant. Even 
now sometimes it is impossible to tell, and may have to wait till end 
of pregnancy. 

I. The Intermittent Uterine Contractions. 

First investigated by Braxton-Hicks ; sometimes called after him. 
By Schultze called "Schwangerschaftswehen." Can be felt from 
the tenth to sixteenth week, and persist till the end of pregnancy ; 
every five to twenty minutes the whole uterus will slowly contract, 
take a more pear-like form, harden, when it slowly relaxes to its 
original form. These contractions are elicited by rough palpation 
or cold hands. They are intermittent, painless, not usually perceived 
by the mother. 

Function. First, they act like a local heart squeezing the blood 
out of the uterus ; when this relaxes, the blood can flow back. The 
circulation in the maternal sinuses is very slow, and it is probable 
that this is the way it is changed. 

Second, the contractions force a certain amount of blood into 
the cervix and vagina. This is especially true during labor it- 



78 NOTES ON OBSTETRICS— JUNIOR CLASS. 

self. It is called Vital Dilatation. It makes the parts soft and 
easily stretched. 

Third, later in pregnancy they cause the fetus to assume a posi- 
tion favorable to labor and keep it from changing its position. Only 
effective to a small extent in multiparae. 

Causes of the contractions : 

1. The fundamental contractions peculiar to all unstriped muscu- 
(ar fibre exist in the non-pregnant uterus and are evidenced by the 
expulsion of a tumor in the uterus, e. g., the extrusion of a fibroid. 

2. Some relation between the movements of the fetus and the 
contractions, as explained above. 

3. External stimuli bring on contractions. 

When the contractions become more frequent and painful, they 
indicate labor beginning. A woman may have painful uterine con- 
tractions for weeks and sometimes months before her confinement. 
These produce no dilatation of the cervix and thus differ from true 
labor pains. This phenomenon is due usually to a neurotic tempera- 
ment. When felt by the obstetrician they are a very certain sign 
of pregnancy, but they can be present (not so rapid or pronounced) 
in : 

1. Soft fibroids. 

2. Hematometra. 

3. Contractions of the recti muscles sometimes imitate them. 
Can all be eliminated; the sign is, therefore, a positive one, and 

may be found irrespective of the life or death of the fetus ; are 
elicited easier the nearer the woman is to term. 

II. Active Fetal Movements, felt, seen or heard by the physician. 
We have already considered the movements as felt by the patient. 
When determined to exist by the doctor, this is a certain sign of preg- 
nancy, of the life of the fetus and also later in pregnancy of the posi- 
tion of the fetus. Are felt as early as the fourteenth week by a 
skilled observer. A gentle tap against the hand, later a distinct 
kick, or a thump if the hand is near the breech and the fetus sud- 
denly stretches or hiccoughs. 

Pinard has listened to the sounds and finds that they can be 
heard as early as the twelfth week. Two sensations, like a gentle 
tap against the ear or the stethoscope, the other a sound like a 
gentle stroke on a tense membrane. 

Place hand with palm over your ear, then gently tap the back 
of the hand with index finger. Sound is identical with fetal move- 
ment. 

Later in pregnancy can see the movements, either a sudden jar- 
ring of the abdominal wall or a limb can be seen traveling across 
the abdomen. 

III. Passive Fetal Movements, i. e., owing to the mobility of 
the fetus in a relatively large amount of liquor amnii, we can give 



^ NOTES ON OBSTETRICS— JUNIOR CLASS. 79 

certain movements to the fetus, called Ballottement, qr, Re-percus- 
sion. 

The sign is elicited in two ways, internal and external Ballotte- 
ment. 

First method: Two fingers in the vagina; hand on abdomen; 
give the body felt in the uterus a gentle tap. There are three per- 
ceptions ; first, that of the body leaving the fingers ; second, that of 
the body striking the other side ; third, that of the return of the 
body onto the fingers. The first and last almost always felt; second 
may not be appreciated. 

Second method: Place the woman on the side of the bed so that 
uterine tumor hangs over ; one hand on each side of the uterus. Same 
procedure. Less certain than the first. 

Get Ballottement from the sixteenth to the thirty-second wxek. 
Before the sixteenth week, fetus too small; liquor amnii too much, 
and walls too thick ; after thirty-second week, liquor amnii too 
little, fetus too large. 

A skillful palpator can perhaps feel Ballottement earlier than 
the sixteenth week. Ballottement gives no information as to the 
fife of the child. 

Fallacies. It may be simulated by the following conditions : 

1. Anteverted uterus floating in ascitic fluid. 

2. Small fibroid or ovarian tumor in ascitic fluid (long pedicle). 

3. Stone in the bladder. 

Care should exclude these and the sign becomes one of high diag- 
nostic significance, really positive. 

IV. Direct Palpation of Portions of the Fetal Body. You may 
feel extremities, called small parts, or head or breech, called large 
parts. 

Many tumors have a nodular contour, and may simulate a fetus 
very much. Case in Berlin where second twin suspected, but it 
was only three fibroids. 

Lumps of feces have led careless observers astray. Carcinoma cf 
peritoneum. Tumors of the omentum. But the sign depends for its 
value on the skill of the observer and may thus attain a high diag- 
nostic significance. 

Can distinguish fetal parts as early as the fourth month some- 
times. In a case of pregnancy where one ought to feel parts of 
the fetus distinctly, the absence of them leads to suspicion that the 
ovum is blighted, or that there is hydramnios. 

V. Auscultation. 

The signs obtained by auscultation may be fetal or muter nal. 
The fetus gives certain auscultatory signs of life, such as the heart 
beat, sounds of fetal movements. In 18 18 Mayor, of Geneva, de- 
scribed the fetal heart tones, but published his paper where few 
saw it. 



80 NOTES ON OBSTETRICS— JUNIOR CLASS. 

In 182 1 Lejumeau de Kergaradec, ignorant of IMayor's article, 
published an extensive paper on this sign, which is classical even 
now. 

Surprising that the sounds were not heard sooner, but then, with 
the exception of a few points about auscultation, given by Corvisart, 
nothing was known about auscultation, even of the adult heart, till 
Laennec published his book in 1819. 

Mayor was looking for the sounds to be made by the fetus 
splashing around in the liquor amnii. Kergardec, also, was not 
looking for the fetal heart tones when he found them. 

The fetal heart tones can be heard as early as the fourteenth 
week, but usually the time is put at the eighteenth week ; always 
at the end of the fifth month. 

Vary in intensity. At first faint, later strong. If large amount 
of liquor amnii, they are weak. If child lies with its back to abdom- 
inal wall, they are heard more distinctly. Cases differ in intensity. 
The stronger the fetus, the stronger the sound. The thicker the 
uterine and abdominal wall, the less the intensity. If the placenta 
lies in front of the fetus, heart tones may be faint or inaudible. 
Other sounds, as the uterine bruit, or rumbling of gas in the mother's 
bowels may cover up the fetal heart tones. 

Up to the fifth month place the stethoscope on the linea alba (or 
the linea nigra, as it is sometimes called), about 8 c. m. from the 
pubis ; after the fetus is palpable, place the stethoscope where the 
heart is anatomically located, i. e., the anterior or posterior aspect of 
the fetus. 

Three Methods of Auscultation. 

I. Naked ear. 
II. Monaural stethoscope. 

III. Binaural. 

Naked ear is not good, because many accessory sounds ; rubbing 
of beard, circulation in middle ear from constrained posture ; fur- 
ther, disagreeable to the patient and to the doctor. In noisy place, 
better than stethoscope. 

The Monaural stethoscope offers the advantage that it is clean, 
easily portable, easily handled, especially during operations (can be 
wrapped in a gauze sponge), and after a little practice gives good 
results. 

The Binaural stethoscope is the most certain, but it is harder to 
carry, harder to disinfect, hard to handle during an operation. Dur- 
ing auscultation nothing must touch the instrument save the skin 
of the mother and the ear of the doctor. Pressure with the fingers 
causes a faint hum which often completely covers the sounds. If you 
must hold the stethoscope on the abdomen do so with two rubber 
bands. 



NOTES ON OBSTETRICS— JUNIOR CLASS. 81 

Characters of the Fetal Heart Beat. 

It resembles the "tic tac, tic tac" heard from a watch placed 
imder the pillow. Tic — short pause, tac — long pause, tic — short 
pause, etc. The first sound, as in the adult is isochronous with the 
systole of the heart, and also with the pulse in the umbilical arteries. 
The second sound or tac is isochronous with the closure of the 
semilunar valves. 

Rapidity: Normally varies from 120 to 150 per minute. Above 
or below these figures points to some pathological condition, if con- 
oiant. Frankenhauser said that the sex of the child could be de- 
termined from the rapidity of the fetal heart tones. He said that 
when the tones were below 135 per minute it was a boy; above 145 
a girl ; between the two, either. Wilson has studied the point and 
finds the rule quite successful. General opinion of observers is that 
no relation exists. My own experience has led me to believe that 
there is little, if any, truth in the theory. In general, the larger 
the child, the slower the beat ; the nearer the end of pregnancy, the 
slower the beat. As boys are usually somewhat larger than girls, 
perhaps something in it. A certain doctor who had a reputation for 
predicting the sex of the child did thus : he asked the patient what 
she wanted; if a boy he told her it was a boy, and immediately 
wrote down in his book, "Mrs. X. will have a girl." After the child 
was born, if a boy, he said nothing (possibly "I told you so") ; if the 
family said he was mistaken, it being a girl, he referred to his book 
and showed that he had made a note that it would be a girl. 

Temperature of the mother increases the beats. Uterine con- 
tractions slow, then later they get faster. Fetal movements ac- 
celerate them. Rapidity varies from hour to hour. During fasting 
they are made rapid and may cease. Threatened asphyxia makes 
them rapid and irregular. 

The fetal heart tones are the most reliable sign we have for the 
diagnosis of pregnancy. Nothing simulates it. The mother's 
pulse is 72 except in fever, etc., and then the intensity will differen- 
tiate (i. e., move your stethoscope nearer the mother's heart and 
the sound w^ll increase in strength). Feel the pulse while listening 
to the fetal heart tones. 

They show, further, the life of the child, and thirdly, can be used 
to diagnose the position of the fetus. They show also if the fetus 
is in danger. An increase persistently above 160 is suspicious. A 
persistent decrease below 100 is suspicious. 

Fetal Souffle. 

This is sometimes called the funic souffle, or umbilical murmur ; 
in German, the Nabelschnurgerausch. It is a soft, blowing murmur, 
heard with the heart tones, svnchronous with the svstole of the 



82 NOTES ON OBSTETRICS— JUNIOR CLASS. 

fetal heart (sometimes with both sounds). First heard by Ken- 
nedy, in 1833. Has its origin in several places. 

1. In the cord, when this is too short or too long, or is coiled 
around the neck, or is lying between the back and the stethoscope, or 
when the cord is inserted into the membranes, or if there are knots 
in the cord. 

2. Due to anomalies of the fetal heart, e. g., perforate septum, 
regurgitation of tricuspids, vegetations on the valves. Thus you. 
may be able to diagnose heart disease in the fetus, if the sound is 
marked, constant in place and rhythm (intensity varies). Heard 
in 14 to 16% of cases examined (Winckel says 75%), but occurs 
later than the heart tones and never without them, so is of less 
importance than they. Was formerly thought to be a sign of fetal 
asphyxia, but this idea is not entertained now. Still, if you hear 
it low down near where the neck ought to be, be on your guard, for 
coils of the cord, and you may get a dead baby. It is by no means 
diagnostic of coils or cord around the neck, merely suggestive. 

When present, is a positive sign of pregnancy. 

VI. Maternal Auscultatory Signs. 

Kergaradec, in his paper, 182 1, described a sound which he heard 
while listening at the sides of the uterus and he ascribed it to the 
rushing of blood through the placenta, calling it the Placental 
Souffle. It is a soft blowing sound, synchronous with the maternal 
heart, having a rushing character, similar to the bruit heard in an 
aneurism or in the veins of the neck, or like the French "vous" pro- 
nounced in a low tone — voo. During uterine contraction it is di- 
minished or altered in quality, sometimes both. 

Position. 

Heard best at the left side of the uterus, low down, but may be 
heard on the right side or anteriorly, occasionally all over the uterus, 
or on both sides. 

Intensity. 

May be loud, drowning the fetal heart tones, or soft, hardly 
audible. 

OcciLrrence. 

Absent in some cases, present on one or both sides, at once or 
alternately. May be heard at one time and absent in the same place 
later, or may disappear while listening. 

Character. 

Humming, blowing, rushing, sibilant or even musical. May be 
continuous, or intermittent, or wavy. Is without shock and is 
usually single, but may be both systolic and diastolic. Sometimes 
may be intensified by pressure with the stethoscope. 



NOTES ON OBSTETRICS— JUNIOR CLASS. 83 

Causes. » 

Various theories : 

1. Placenta. Not here, as it can be heard after the placenta is 
removed. Can be heard where the placenta is not. Up to now no 
sound has been heard that can be attributed to the placenta, so that 
it is not possible to diagnose the position of the placenta by this 
sign. 

2. Compression of the iliac arteries by the uterus. Not so 
because, first, it is heard at a time when the uterus could not com- 
press the arteries (that is, the twelfth to the fourteenth week). 

Second, in the knee chest posture, the sound is also heard. 
Third, the specific gravity of the pregnant, non-contracted uterus 
is but slightly, if any, more than that of the intestines. 

3. Compression of the epigastric artery by the stethoscopie. Can 
be excluded (Glenard). 

4. Occurs in the puerperal artery. Should be constant. 

5. Theory of Dubois. The arteries enter the uterus and empty 
into large venous sinuses. They also are very tortuous. The mur- 
mur occurs here and is similar, therefore, to the murmur in a vari- 
cose aneurism ; sometimes the fetus will compress a certain part of 
the uterus and then the murmur will be increased. Sound is heard 
as early as the twelfth week ; Spiegelberg says the sixteenth week, 
and is a probable sign of pregnancy. Occurs if the fetus is dead or 
alive. 

Fallacies. 

1. Rapidly growing uterine tumors have the same murmur. 

2. Any pelvic tumor growing and causing greatly increased 
vascularity of the pelvis. 

There are other sounds heard in auscultating the abdomen. 

1. The maternal heart tones. When there is gas in the intes- 
tines the sound is conveyed thus, sometimes even to the pubes. 

2. The tones audible in the arteries of the lower pelvis. 

3. Borborvgmus, which must not be mistaken for the fetal heart 
tones. 

4. IMuscular movements of the abdominal walls. 

VII. CHANGES IN THE FORM, SIZE, POSITION AND 
CONSISTENCY OF THE UTERUS. 

Form. 

Uterus more and more globular. A symmetrical globular tumor ; 
on each side can usually feel the round and broad ligaments hanging 
down. Can sometimes^feel the ovary, especially the left, and it may 
be quite tender. 



84 NOTES ON OBSTETRICS— JUNIOR CLASS. 

* Size. 

Uterus rises above the brim of the pelvis at the end of the third 
month ; fourth month it is three figers above the pubes ; fifth month 
half way to navel ; sixth month, at the navel. Growth is quite uni- 
form in primiparae, but one cannot use these points to determine 
the length of the pregnancy, because a full bladder, full rectum, 
hydramnion, etc., confuse. The size of the uterus at the different 
months of pregnancy varies in different women and remarkable as 
it may seem, in the same woman at different days or weeks of the 
month. In rare cases, the uterus may suddenly enlarge to the size 
of a uterus several months longer pregnant, and then as suddenly 
subside to its original size and form. Dr. O. Buettner, Centralblatt 
fur Gyn. in Aug., 1900, describes cases of this kind, also R. L. Dick- 
inson, Am. Gyn. Soc'y, 190 1. 

The writer met one such case. Cause not known, likewise path- 
olog}^ Uterus may grow unevenly, so that the ovum seems to be 
in one side only. Then, too, the uterus can alter its usual globular 
form. Ovum may be situated in one corner of the uterus. 

Position. 

Median symmetrical tumor, lying against the abdominal wall. 
The bladder in filling gets in front. Useful for diagnosis. 

VIII. Changes in the Skin. 

The stretching continuing, the linea gravidarum increase. The 
navel in the first months is drawn down, then becomes pouting ; in 
the third three months is drawn up and when lightening occurs it 
becomes pouting again. 

The presence of marked varicosities of the legs and vulva is sig- 
nificant of pregnancy, and the absence, if they have been marked at 
other times, is likewise significant. (See previous chapter.) 

IX. The Determining of the Rate of Grozvth of the Uterus. 

In an experienced hand this sign is positive. No tumor grows 
like it. Examine bimanually and note the size at intervals of two 
weeks. If the tumor doesn't grow, or gets smaller, the ovum is 
blighted. 

SUMMING UP OF SIGNS OF THE SECOND TRIMESTER. 

I. Subjective. 

a. Menses absent ; highly probable. 

b. Active movements of fetus ; probable. 

II. Objective. 

a. Painless uterine contractions ; certain. 

b. Active fetal movements felt bv doctor ; certain. 



NOTES ON' OBSTETRICS— JUNIOR CLASS. 8i 

c. Passive fetal movements, ballottement ; certain. 

d. Direct palpation of fetal body ; certain. 

e. Auscultation, fetal heart tones, feta] souffle, fetal movements 
certain. 

f . Auscultation ; uterine bruit ; probable. 

g. Changes in form, size and position of uterus ; certain, 
h. Linea albicantes and navel ; presumptive. 

i. Rate of growth of uterus ; certain, in skilled hand. 



SIGNS OF THE THIRD TRIMESTER. 

No new signs develop. 

Menses still absent. 

Morning sickness absent, usually. There may be some sickness, 
but it is most often pathologic and you must direct your attention 
to the kidneys at the first sign of sickness in the last three months. 
Still it may occur from interference with the digestion due to the 
cramped position of the stomach. 

Active fetal movements persist, may become so violent as to dis- 
turb the woman's rest, and this, too, without any assignable cause. 
Women usually feel these on one side, particularly that side where 
the feet are, — is of 'no use to diagnose the position of the child. 
Just before labor the infant is quieter. 

Objective Signs. 

Re-percussion is limited to certain parts of the fetus unless there 
be a condition known as Hydramnion, i. e., increase of the liquor 
amnii, which gives a much increased mobility to the fetus. 

Fetal heart tones are louder and more constantly heard in one 
place. Palpation of fetal parts is plain, and towards the end of this 
trimester is like that of labor. 

Uterine bruit till the seventh month increases in intensity, after 
this remains about stationary. 

I. Changes in the uterine tumor, however, are marked. 

At the seventh month uterus reaches one-third of the distance 
from navel to the ensiform appendix; at the eighth month, two- 
thirds the distance, and at the ninth month, about the level of the en- 
siform appendix. In primiparae now the uterus sinks into the pel- 
vis, i. e., the lightening. In multiparae this does not occur till just 
before or during labor. Still in some cases occurs also in multiparae. 

The regular advance of the uterus, also, is only true of primi- 
parae, as owing to the loose abdominal wall of the pluriparae the 
uterus can fall forward and cause pendulous abdomen. 

Lightening before labor is attended with certain improvement 
in the symptoms. The breathing is easier, digestion better, not so 
much heartburn or palpitation. Still, the patient cannot get around 
as well, i. e., locomotion is hindered. Bladder symptoms exagger- 
ated. Neuralgias in the lower extremities, from pressure on sci- 
atic and obturator nerves. All due to the presence of the head in 
the pelvis and its pressure on the various structures. 



NOTES ON OBSTETRICS— JUNIOR CLASS. 87 

Lightening has an important prognostic vakie. It means that 
the head of the fetus can pass into the pelvis and that there exists 
no disproportion between that particular head and that particular 
pelvis. As the inlet of the pelvis is most often contracted, the head 
in the pelvis shows that for this case the inlet is normal. In some 
cases the head passes out of the pelvis again and may be found at 
several examinations either in or out. Lightening may be absent in 
the following conditions : — 

1. Contracted pelvis. Where the inlet of the pelvis from one 
disease or another is smaller than normal, the head will not enter. 
Often during labor the head will not enter and this forms one of the 
most im.portant obstacles to natural delivery. 

2. In twin pregnancy, head does not engage till labor begins. 

3. In hydramnion, i. e., increase in the amount of liquor amnii. 

4. Multiparity. 

5. Presence of the placenta in the lower uterine segment. 

6. Occipito-posterior positions. 

In primiparae the non-engagement of the presenting head must 
make you look for something Avrong, but you will not always find 
a contracted pelvis. 

II. Changes in the contour of the abdomen in the last three 
months. The profile of the abdomen is a quite even curve till the 
head sinks in the pelvis, then, owang to the anteversion caused by 
the tension of the round ligaments, the fundus falls forward. The 
uterus sinks to the level it had at the eighth month, but the abdomen 
becomes more prominent. The w^aist measure is increased ; the 
woman has to let out her skirts. 

III. In the last four zceeks, also, changes in the uterus' form 
take place. This is owing to the development of the lower uterine 
segment. The head passes into the low^er part of the uterus, which, 
according to Schroeder, is from the body of the uterus, and accord- 
ong to Bandl, from the expanded and dilated supra vaginal portion 
of the cervix. The changes in multiparae are not so constant. Lower 
uterine segment does not form till labor. 

The formation of the lower uterine segment is caused by several 
factors, and may be part of the process of lightening. 

1. The weight of the child. 

2. The intermittent uterine contractions. 
, 3. Action of round ligaments. 

4. The tightness of the abdominal wall, and this is the reason 
that it is less likely to be formed in multiparae than in primiparae. 

5. The presenting part is relatively immovable in the inlet. The 
fundus of the uterus becomes more flattened, less convex, due to : 

1. Entrance of the head in the lower uterine segment. 

2. Absorption of liquor amnii, which allows the uterine w^all 

to apply itself more closely to the body of the fetus, 



88 NOTES ON OBSTETRICS— JUNIOR CLASS. 

especially to the breech with the extremities doubled 
against it. 

IV^. Changes in the Vaginal Findings. 

Up to the last three weeks, the cervix is felt as a soft, not easily 
outlined body in the vault of the vagina. Its conical shape can still 
be defined, but with difficulty, owing to its succulence. The finger 
can be passed half way to the internal os in primiparae, but all the 
way usually m multiparae, and in rare cases also in primiparae. If 
the head has not yet gotten into the pelvis the cervical canal is 
directed backward, the cervix can be felt as such. Sometimes the 
cervical canal runs forward. If the head has gotten into the pelvis 
the cervix seems to be flattened out (usually called "apparent efface- 
ment of the cervix"). The canal is directed forward. The ordinary 
position may be recovered by traction on the anterior lip of the cer- 
vix. 

THE DIAGNOSIS OF THE TIME OF PREGNANCY, 
or THE PREDICTION OF THE DAY OF CONFINEMENT. 

(See Winckel, Volk. Klin, Vort N. F., No. 292.) 

For many reasons, on the part of the doctor and the patient, it is 
important to know the time of labor. The doctor may want to in- 
duce labor for contracted pelvis, or to admit the patient to the hos- 
pital. The patient wants to know so as to arrange her household 
affairs, to engage a nurse, etc. It is a matter of some moment to 
come within two weeks. But we cannot tell positively when labor 
will occur. There will always creep in a discrepancy of one to three 
weeks, since the real duration of pregnancy is not known. 

1. The time of conception is not known. Conception may have 
occurred after the last or before the first period missed. 

2. The occurrence of labor is often accidental, i. e., it may be 
brought about by some little accident, e. g., going up stairs, a jar, 
a diarrhea, or excitement. 

3. Length of pregnancy varies with women, and in the case of 
same woman at different times. True of all animals. 

Pregnancy varies from 240 days to 320 days. French law rec- 
ognizes as legitimate a child born six months after the marriage and 
300 days after the death of the husband. But pregnancy may be 
prolonged over the usual time, reckoning according to menstrua- 
tions. Since we have all these sources of error, mistakes are com- 
mon and one's diagnosis, therefore, can only be probable. 

The following points are used in the determination of the date: 
a. The date of the fruitful or single coition. This may be known. 
Some women say they can tell when a coition is fruitful by a pecu- 
liar sensation at the time. No truth in it. Date of single coition 



NOTES ON OBSTETRICS— JUNIOR CLASS. 89 

more likely, e. g., sudden death of husband, rape. Count 272 to 275 
days or nine calendar months from this date. 

b. The date of the commencement of the last menstruation, 
Schultze's rule, count back three months and add 7 days ; e. g., 
May i6th — February 23rd. 

Or count ahead 280 days from the commencement of the last 
menses. This is subject to fallacies (three weeks). There are many 
rules, calendars, formulae, etc., but they are all juggling with the 
same figures. 

c. Date of quickening. If the woman comes to you before 
quickening, tell her to notice when it occurs and write down the 
date. Count ahead twenty-four weeks in multiparae, twenty-two 
weeks in primiparae. But sometimes quickening is felt later and 
again not at all, so little certainty ; the sign has this value, however, 
that it acts as a check on the other dates. 

Objective Signs. 

1. Si^e of the uterine tumor, distension (circumference) of the 
abdomen, height of the fundus above the pubis, or the navel, or the 
ensiform, are very doubtful signs, as they may be affected by so 
many disturbances, e. g., fat or thin woman, tumors in the abdomen, 
hydramnion, full bladder and rectum, fetus transverse or a monster, 
twins. 

2. The size of the fetus, m^ore constant and the best guide, but 
more useful to the old practitioner. Two ways ; one, direct measure- 
ment of the fetus by calipers, or Ahlfeld's method. He says that 
owing to its flexed posture the length of the fetus from head to 
breech equals one-half the length of the whole body, and since the 
length of the body is the most certain measurement, we have the age 
of the fetus, if we can measure it in utero. 

In primiparae one branch of the calipers or pelvimeter put inside 
the vagina against the head, other branch rests on the breech of the 
fetus. Double this to get the length of the fetus. 

In multiparae one branch rests on the pubis, the other the breech. 
(Reason is that in multiparae the head does not enter the pelvis.) 
To figure out the time double the result gained, subtract 2 for the 
thickness of the soft parts, divide by 2 and you will get the number 
of months ; the fraction represents the weeks. Example : 24x2 equals 
48 — 2 equals 46 divided by 5 equals 9 1-5 months. This is a very 
uncertain method. But it must be controlled by numerous measure- 
ments taken when the uterus is not contracting. Take the average 
of many trials. If the child is transverse, take both branches of the 
sides of the uterus, over head and breech. 

Direct measurement of the fetal head has been practiced, espe- 
cially in France. The ends of the pelvimeter are placed against the 
head through the abdominal wall. Allowing ^^ to i cm. for the 



90 NOTES ON OBSTETRICS— JUNIOR CLASS. 

thickness of the latter, and allowing i to 2 cm. for the oblique diam- 
eter of the head in which it must necessarily be grasped, we can ar- 
rive at an estimate of the bi-parietal diameter. The position of the 
head must be determined by palpation. Very accurate measurements 
can sometimes be taken, and the value of the procedure increases 
with experience. Especially useful in determining the time for 
inducing labor in contracted pelvis. 

Carl Braun would grasp the fetus, especially the head, and by an 
intricate mental process would determine the size and development of 
the fetus, just as you judge the weight of a baby. This, also is sub- 
ject to fallacies, and some children develop faster than others, e. g., 
a child may weigh 9 lbs. at 9 months — another woman at the tenth 
month may have a child weighing 6 lbs. It seems to the writer, also, 
that the rate of growth of a given child varies from month to 
month, besides the normal increase in size. The parts of a child 
develop unequally ; some children have large heads and small bodies, 
others small heads and large bodies. One case, the legs were out of 
proportion to the body, being twice the size they should be, to be 
in proportion (Mercy Hosp., 1903). 

^..Lightening before labor, and the changes in the lower uterine 
segment and cervix. Reckon three weeks from the "settling," as 
it is called. Examination in the last three weeks reveals important 
changes in the lower uterine segment in primiparae. 

The head entering the pelvis, the cervix seems flattened out, 
effaced, looks forward, canal runs backward. In multiparae and 
in primiparae before lightening, the cervix is retained, in multiparae 
the patency of the os shows the near approach of labor (Schroeder). 
Sometimes, even weeks before labor, one can pass two fingers into 
the cervix to the membranes. In the majority of cases you can arrive 
at a pretty close estimate which will get better as your experience 
grows. Put the responsibility on the woman, however, telling her 
you are relying on the dates she gives you for the computation. 

MULTIPLE PREGNANCY. 

The development of two ova in utero means twins. Term gen- 
erally not applied to fetuses, one inside, one outside the uterus (extra 
and intra uterine pregnancy co-existing). 

Twins occur, one in eighty-seven to eighty-nine labors. Triplets 
occur one in 8,000 cases, four at birth occur one in 400,000 ; five very 
rare, while six, which have been observed, are excessivelv rare. 

Twins come from 

(i) Tw^o distinct Graafian follicles, which may come from one 
ovary or one from each ovary ; 

(2) From two ova in one Graafian follicle ; 

(3) From one ovum. 

The first is proven by the occurrence of two corpora lutea. The 



NOTES ON OBSTETRICS— JUNIOR CLASS. 91 

second is proven by the presence of two ova in one Graafian follicle, 
which has been repeatedly found in microscopic sections. 

Three have been demonstrated in one Graafian follicle and Crede 
has had triplets with one chorion. (M. F. G. B'd 30, p. 96.) 

The third is explained by the appearance of two primitive streaks 
and the development of two children from one ovum. If the fission 
of the two streaks is complete we have twins, if not complete a 
double monster results. Another theory is that there is one primary 
streak, but that it divides later. 

Causes of Tzmns. 

Acting cause unknown. Predisposing causes may be mentioned. 

(1) Heredity. Seems to be transmitted in the female line, but 
cases where male has had twins by different women are on record. 
(See Parvin.) 

(2) Multiparity. Twins more frequent with multiparae ; perhaps 
because multiparae more frequent. 

The structure of the fetal membranes in twins varies with their 
origin from one or two ova. // from one ovum we will have one 
chorion enclosing two fetuses each surrounded with amnion. Thus, 
in the septum between the fetuses we will find simply two layers of 
amnion. If from two ova — whether these be from one Graafian or 
two Graafian follicles — we will have two chorions, one for each four 
layers. Sometimes the decidua will persist between the two eggs 
and show itself in the septum, therefore, six layers in the septum, 
but this is rare and when it occurs the deciduae are fused and the 
amount of decidual tissue is not great. 

The twins from one ovum occur in 13% of cases (x\hlfeld). 
They usually have one placenta and their circulations anastomose 
in the placenta as well as on the surface. Therefore, the twins de- 
velop equally and have the greatest common characters, e. g., appear- 
ance, development, sex ; always of the same sex. Even in after life 
the resemblance is great. This anastomosis of circulation is not inva- 
riable. 

Twins from separate ova have either separate placentae, or if the 
ova should have happened to locate near each other in the uterus, the 
placentae will lie in close apposition or will run into each other and 
anastomosis of the vessels also occurs. Still the placentae may lie 
apart, separated by a space more or less wide. Twins from these 
ova may or may not be of the same sex, and often present unequal 
development. One may die, the other live. One may be syphilitic, 
other healthy. 

The ova may occupy different positions in utero : 

(i) One alongside the other; 

(2) One behind the other ; 

(3) One top of the other. 



92 NOTES ON OBSTETRICS— JUNIOR CLASS. 

Combinations can occur (see Budin Arch de Toe, 1883, p. 140). 
In a few cases where the septum has consisted of two amnions 
the sacs have communicated. Unknown if the septum has been ab- 
sorbed, necrosed, or if one had formed at all. In these cases the 
cords may be twisted and death of the fetuses may result. Has been 
rarely observed in the human female. Twins are smaller than sin- 
gle children, but together usually weigh more than the one. 

Due to the fact that there is only a certain amount of nourish- 
ment, of vitality of the mother, of placental area, and also because 
the pregnancy is usually terminated before the full period is com- 
pleted. Women of the more intelligent classes object to having 
twins on the ground that their development, especially the mental, is 
below that of single children. 

This is true of their physical condition and the mortality of early 
childhood is very large. Of their mental development, opinions 
differ. An interesting formation occurring with single ovum twins 
is the acardiacus, a fine specimen of which is in the college museum. 

The allantois, in early ernbryonic life, of one fetus grows on the 
territory of the other fetus, the heart of the latter atrophies, and 
the fetus wastes to a mere lump of flesh supported as a parasite by 
the healthy one, and nourished by an artery and a vein from its pla- 
centa. There are different form.s of acardiaci, head, feet, or trunk, 
depending on what part of the original fetus is preserved. The one 
mentioned is an acardiacus acormus, or trunk. 

Diagnosis. 

Only once have three fetuses in utero been diagnosticated before 
labor and this by Pinard of Paris. He found three heads and 
naturally diagnosed triplets. 

Your attention may be called to the possibility of twins by an un- 
usually large abdomen for the given period of pregnancy; great 
aggravation of the congestion symptoms, e. g., edemas, albuminuria ; 
a very globular uterus (hydramnion) indefinite palpatory findings ; 
lastly, finding more parts than can belong to one fetus. 

In general you must be very careful how you diagnose twins. 
Many mistakes have been made. Capuron in speaking to Pajot one 
day said, "When I find one child in the uterus after I have delivered 
one, I say there are twins." In labor not so hard to diagnose. 

The points in the diagnosis are : — 

(i) A groove felt in the fundus. Can occur with uterus arcua- 
tus, or double horned uterus, or even in ordinary labor, and is often 
absent in twins. 

(2) Usually large size and globular form of the uterus. Occurs 
in hydramnios, which may complicate twins. 

(3) Absence of engagement of the presenting part. Can occur 
with hydramnios, and breech presentation, etc. 



NOTES ON OBSTETRICS— JUNIOR CLASS. 93 

(4) Palpation of three large parts. In diagnosis we use the 
terms "large parts" and "small parts/' If you feel two heads and a 
breech, or two breeches and one head, can diagnose twins. Do not 
do it on the multiplicity of the small parts or on the statement from 
the mother that she feels movement all over the uterus, or at differ- 
ent, distant places in the uterus. 

(5) The auscultation of two different sets of heart tones. 

(a) They must not be synchronous. 

(b) They must have a free zone between. 

(c) Must be heard at the same time, therefore two men 

should listen. 
The patient must not change her position during the examina- 
tion, the tones must be counted many times on each side and aver- 
ages made, the difference must exceed 10 to the minute. Great care 
and circumspection needed to be certain. 

(6) Mensuration from head to breech; if w^hen doubled gives a 
length too long for one fetus, perhaps twins, 

(7) Vaginal touch may reveal two bags of water with a groove 
between them (Depaul). 

(8) Sometimes after one bag of waters is ruptured you may 
feel a fetus in a second unbroken bag of waters (De Lee). 

Be very careful in your examination and you can almost always 
arrive at a highly probable diagnosis, but do not tell the patient, as 
it will cause her needless worry. Tell some relative so that they 
will not say you did not know it. If not quite sure say nothing. The 
majority of twins are diagnosed only after the first child is born. 

DIAGNOSIS OF MULTIPARITY. 

Sometimes necessary to tell if a first or second pregnancy, or 
that pregnancy has occurred. Can almost always be told if sufii- 
cient care used, but if more than five years have elapsed since the 
birth of the last child, if it was small or prematurely born, or re- 
moved by crushing operation or Cesarean Section, or if patient be 
large, it may be impossible to determine, as the only signs we have 
are those caused by the trauma of labor. 

1. The deep rupture of the hymen and perineum. If there is a 
tear of the perineum and no operations have been done or history of 
injury, a positive sign. 

The rupture of the hymen, however, is not so certain a sign. 
Superficial tears occur in coitus, deep tears, forming later the carun- 
culae myrtiformes, occur only during labor (Schroeder). Still a 
woman may have no hymen congenitally, or it may be so distensible 
that it does not tear during labor. Generally scars around the vul- 
var orifice are suspicion^ of a labor. 

2. The deep tears and scars in the cervix. In primiparae the cer- 
vix has a round os, and a conical portio vaginalis. In multiparae the 



94 NOTES ON OBSTETRICS— JUNIOR CLASS. 

OS is a transverse slit and the cervix more cylindrical or perhaps the 
lips are everted, thus the cervix seems to be divided into an anterior 
and posterior lip. Scars may be present which in the absence of an 
operation are positive. Especially to be seen when the cervix soft- 
ens up during pregnancy. Scars in the vagina also. An infant in 
arms has had eversio cervicis and prolapsus uteri. 

A chronic cervicitis may in a virgin produce similar conditions. 

3. The vagina in a nulliparae is rough, rugous, tight. After 
bearing a child, smooth, larger, softer. 

4. Mammary glands deeply pigmented, flabby ; colostrum. Striae 
gravidarum may be found. 

5. Striae Gravidarum occur in fat people and tumors, and absent 
in six to ten per cent of pregnancy cases. Abdomen not tight, some 
diastasis of the recti muscles. 

Still you are never in a position to assert positively. Say, "It is 
consistent with the facts in the case tiiat this woman was or was not 
pregnant." You can usually be positive of the occurrence, but you 
can never deny its having occurred, especially now when so many 
operations on the genitals are being performed. Women wanting 
to hide the condition will say an injury or an operation was the 
cause of the scars. 

DIAGNOSIS OF THE LIFE OR DEATH OF THE FETUS. 

Consider the fetus alive in the absence of positive evidence to 
the contrary. One can seldom assert with positiveness that a given 
fetus is dead ; can assert it is alive. If the fetal movements are 
heard or felt by the doctor or if the fetal heart tones audible, or the 
funic souffle, fetus is alive. In a healthy woman usually safe to 
assume fetus is alive. 

Signs of the Death of the Fetus. 

1. Cessation of the movements after having been felt by the wom- 
an and doctor. Must persist in many examinations. Presump- 
tion only. 

2. Absence of heart tones after being heard (careful and fre- 
quent auscultation). Presumptive value only. 

3. Palpation of the abdomen. Uterus and fetus do not have the 
elasticity characteristic of a living ovum. 

4. Through vagina can feel that the head is softened. The bones 
movable on each other, within the scalp. Determinable within nine 
days, sometimes earlier. Certain sign, but often hard to elicit. 

5. The temperature of the vagina sinks a little. It is usually .5 
degree C. higher when the fetus is alive. (Little value.) 

6. Discharge of altered liquor amnii, e. g., bloody or milky. 
Fetid liq. amnii not incompatible with a living child. 



NOTES ON OBSTETRICS— JUNIOR CLASS. 95 

/. Languor, malaise, sinking of the breasts, loss of weight can 
come from too many other causes to be of use. Loss of weight is 
the most reliable, since a woman should gain weight the last four 
months. 

8. Cessation of growth of uterus. Valuable sign if carefully 
watched. Uterus instead of growing gets smaller, harder, more 
evenly resistant all over. The intermittent uterine contractions are 
more frequent, more marked, and there may be an occasional dis- 
charge of blood, or bloody mucus. Even this sign subject to falla- 
cies, (a) the mentioned findings may be absent when the fetus is 
dead, or present when it is alive, (b) The uterus may enlarge after 
death of the fetus, due to degeneration of the ovum, e. g., hydatidi- 
form mole. 

9. Woman gives a history of losing several children at a certain 
month in pregnancy and now has identical symptoms. 

10. Findings in the urine, e. g., acetone, peptone, not reliable. 
The languor, malaise, light chills, bad taste in mouth, may be 

explained by the absorption of toxins, similar to those of degene- 
rating tumors, e. g., fibroids. When a cause exists for anticipating 
fetal death, the diagnosis is rendered easier. Such conditions are 
syphilis, eclampsia, nephritis, high fever, cholera, etc. 

Can seldom make positive diagnosis. Anyway no need to do any- 
thing, since if the fetus is dead, delivery will soon occur. Not neces- 
sary to induce labor. No harm results from the condition except in 
the rarest instances, and if patient is properly watched the time for 
interference can be safely determined. 



HYGIENE OF PREGNANCY. 

Women call the doctor and engage him for their confinement 
earlier now than formerly, earlier among the better classes than the 
poorer, earlier in the city than the country, earlier in the United 
States than in England. There is a great advantage in this, in that 
it may enable the doctor to learn the traits or constitution of his 
patient, watch for any symptoms of disease and prepare her prop- 
erly for the labor; therefore encourage this in your practice. .. 

You will have many and varied questions to answer and it is 
well if you are acquainted wath the subject. See Surbled. La Vie 
a Deux., p. 127. 

General Rules. 

1. Patient should not change good habits ; it is well if she should 
have no bad ones to change. She should pursue her usual course of 
life. 

2. Dress. There should be no circular constriction at any part of 
the body. Corsets should not be worn after pregnancy is diagnosed. 
The Latin term for the condition of pregnacy was "incincta," with- 
out a girdle, and had reference to the laying off of the girdle when 
pregnant. This term is preserved in the French as ''enceinte.'" You 
will have difficulty in enforcing this rule. A good substitute is the 
Ferris maternity waist, which must be worn loosely. No steels in 
the corset, if worn. All dresses should hang from the shoulders, 
using suspenders, if necessary, or buttoned onto the waist. 

Flannel should be worn next to the skin, both in summer and 
winter, heavier, of course, for the latter. Union suits are good. 
Better wear fewer skirts and heavier drawers, than heavy skirts. 
These cause pain in the back, headache, etc. 

Low-heeled shoes and have the big toe in a straight line with the 
inside of the foot if possible, so-called orthopedic shoes. Women 
warmly shod. 

3. Diet. In general the diet should be the same, excepting 
highly spiced, puddings, fatty, fried starches, etc. She should eat 
heartily, but not s:luttonousl3^, thinking she is eating for two. Three 
meals a day sufficient. If the vomiting deprives her of her break- 
fast, let her wait a few hours and then try again ; by no means let 
her go to the pantry and eat cold pie, etc. Water should be drunk 



NOTES ON OBSTETRICS— JUNIOR CEASS. 97 

freely, at least five full glasses a day ; sterilized or filtered. Alcohol 
better left alone. Wines bad, better be left alone, unless some indi- 
cation for them. Eat cereals, especially oatmeal, because it contains 
a large percent of calcium salts ; cracked or rolled wheat. Bread 
made from whole wheat flour. These tend to correct constipation. 
Still must be given with care if the patient be used to lighter articles 
of diet, as they cause indigestion and sometimes constipation. Eat 
fruit in large amounts, especially those that have fruit acids, such as 
apples, and such as contain sugar, e. g., grapes, pears ; stewed or 
better raw. 

A'egetables, but not those that have too much cellulose, e. g., 
cabbage. It is believed that these, by accumulating in the bowels, 
cause reflex irritation and perhaps eclampsia, bleats may be taken 
once a day. If there is any kidney trouble meats are to be avoided. 
Same to be said of broths. In fat people limit the whole diet, espe- 
cially fats and water, but the amount of urine must not be allowed to 
get below 32 oz. Strong tea and coffee to be avoided at all times. 
IMilk and eggs to be used freely. If kidney troubles, buttermilk. 

Breakfast should be light, without meat. Dinner at noon, with 
one meat, plenty fruit, raw or cooked and vegetables. Supper light. 
Fluids sparing at meals, freely between them. 

For the constipation of pregnancy, regulate the diet in the way 
indicated ; prescribe sufficient exercise, a glass of cool water before 
breakfast ; habit all to be used. Figs, dates, etc. 

Withhold drugs as much as possible. Of drugs cascara is the 
best. Active cathartics with caution. Co. Lie. Powd. Dr. ss before 
bed. In hemorrhoids may use aloes. If causes pain, stop. Enemata 
of oz. ii warmed olive oil, or oz. viii warm salt water ; don't use too 
much ; dilates the bowel. A good combination for atonic constipation 
is Ext. Case. Sag. m. x, Tr. Rhei, Arom. m. x, Tr. Nuc. Vom. m. v. 
4. Exercise. Violent exercise, of course, to be avoided. It is 
not possible to build up a weak muscular system during pregnancy. 
That should have been done before. To be avoided are jolts, run- 
ning, sudden lifting, great weights, going up and down stairs 
quickly, horseback riding, cycling. (See jMiddlemarch, by George 
Eliot.) Riding over rocky roads, etc. 

To be encouraged are walks up to one-half mile in the sunlight, 
not at night. In winter careful not to slip. Housework, but no 
washing and not too heavy bed making. Easy carriage drives. 

Railway travel, automobile, and voyages better be avoided at all 
times. 

If a short journey, allowable. Pinard says that frequent travels 
on the railway in the early months of pregnancy conduce to the 
formation of placenta previa. Advise against them. Patients almost 
always go anyway, therefore if something happens the blame will be 
where it belongs. 



98 NOTES ON OBSTETRICS— JUNIOR CLASS. 

Coitus During Preguaucy. 

Has been said that a woman has a disHke for coitus during preg- 
nancy. True in some cases, in others an increased desire, may be 
nymphomania. Subject one of importance, as is evidenced by the 
many pubhcations on the subject. There are many reasons why 
coitus should not be performed during pregnancy. 

1. The danger of abortion, impact of the penis against the cer- 
vix, or the great congestion of the act may cause abortion. No 
doubt that the frequency of abortion in young married people is due 
to this cause. They think that since pregnancy exists, no danger, 
and therefore are excessive. 

2. Nervous shock not borne well by a woman already taxed with 
demands on her nervous energy. It often increases the nausea and 
vomiting. In some cases the sight of the husband will bring on an 
attack of vomiting. Removal from home may cure it. 

3. Animals do not copulate when the female is pregnant. Some 
one said, "We do not take pattern after animals in other matters." 
Still in some cases wx might do well in allowing the instinct of ani- 
mals to guide us. 

4. Danger of infection. . Specially in multiparae with patulous 
cervix. 

Copulation during the first four months is more dangerous than, 
later. During the last month the uterus has attained a high state 
of excitability, therefore copulation ought not to be allowed. Some 
women will admit the male up to the time of labor ; in such a case 
puerperal fever might close the scene. Some doctors use the rule 
that between the fourth and eighth months copulation at the desire 
of the female only. Other reasons than have been given are that 
it takes the strength away from the fetus, that it makes the fetus 
sensual (maternal impressions), that it causes the wife to lose her 
respect for her husband, etc. ; all have more or less truth in them. 
It would certainly be better for every one that coitus be not practiced. 
Advise against it so that if something happens the blame will be 
where it belongs. 

Bathing. 

Cold baths and hot baths in general should be avoided. A cold 
plunge in all cases avoided, but if the patient is used to cold w^ater, 
no objection to cold sponge bath. 

No hot baths or hot sitz baths allowed. Danger of exciting con- 
tractions of the uterus by either, especially the hot. 

Tepid bath may and should be taken freely, at least four times a 
week, preferably daily. Object is to keep the ''pores open," to stim- 
ulate the skin, to excrete efifete matters and thus relieve the kidneys 
(a point that cannot be overestimated) and for cleanliness, since 
pregnant woman secretes more. Salt bathing at home has some 



NOTES ON OBSTETRICS— JUNIOR CLASS. 99 

use, but sea bathing and swimming must be prohibited, as a powerful 
cause of abortion. Turkish and Russian baths prohibited during 
pregnancy. Some women do not react after bathing, but are weak- 
ened. Here the bath must be restricted. 

Vaginal douches may be given during pregnancy. Rule, always 
tepid, at low pressure, and a fountain syringe; exclude air. Sterile 
water, or if discharge suspicious, 1/2000 Permanganate of Potash 
or 1% lysol Not to be used unless really necessary. 

Mental Occupation. 

Woman is impressed with the duties of a mother and wants to 
know what to do and what not to do. She should busy herself (for 
nothing is so bad as idleness) in reading, painting, etc., as usual. 
Recommend good books. If she believe that if she reads good books, 
etc., her child will be bright and'intellectual, humor her. Some 
authors claim that if woman visits galleries of art, etc., with one 
child, and reads astronomy with the second, she will get an artist 
and an astronomer. 

A good guide for the woman to use is that of Pye Henry Che- 
vasse. It is written in an engaging style and contains many sensi- 
ble points. It is thoroughly English, however. Few women 
really need books about labor, but they will sometimes persist and 
get a bad one, like Tocology, so advise the above to prevent it. 

A primipara is likely to be despondent and anxious to be over 
her trial. Assure her that with good care before and during labor 
all cases are normal, which you can consistently do with 96% of 
cases of normal pregnancy and labor. 

Qiurch and theater going, to be restricted, because the CO2 
and generally bad air may injure the fetus, or in the crowds which 
sometimes take place, she may be jammed, and further, it is not in 
good taste. Pregnancy is by all means honorable, but she should not 
intrude it on the public. 

A few words about Maternal Impressions: 

Reference has already been made to the effect of impression on 
the mother's mind causing physical deformities of the fetus. The 
mother as well as the father may impart certain traits physical, as 
well as mental, to the offspring. It has been denied that any im- 
pression made on the mother during pregnancy can cause a change 
in the mental conditions, or the shape of the child : 

1. Because no nerves ever were demonstrated in the tmibilical 
cord. Virchow himself could find none. 

2. The child is completely formed by the end of the sixth week 
and pregnancy is seldom recognized at this time. 

3. All monstrosities in the human have been observed in the low- 
er animals, and no one will admit that a pig with one eye and nose 
above it was the result of an impression made on the sow's mind. 



LofC. 



100 NOTES ON OBSTETRICS— JUNIOR CLASS. 

(This iPiOnstrosity is called c)xlops, fine examples in man and beast 
in the college museum.) 

Arguments without number, and many cases, have been ad- 
duced on each side. The weight of opinion is against a direct im- 
pression of the fetus, e. g.', where a woman sees a man minus a leg 
and gets a child minus a leg; but the health of the mother can and 
does influence the growth of the child. At present we can neither 
affirm nor deny the influence of maternal impressions. 

Care of the Breasts. 

It is important that the breast be put into the best possible con- 
dition for nursing. Tendency for American women not to nurse 
their children was on the increase. A telling and very successful 
crusade against this is being carried on. It is a great misfortune, 
both for mother and child, if the mother does not nurse her infant ; 
for her, in that she is likely to have sub-involution of the uterus, 
and for the baby in that it is poorly nourished, may die in its earlier 
months and may not be strong all through life. Further, the ques- 
tion of expediency. A wet nurse is often the beginning of domestic 
v/ar and unhappiness, the Arnold sterilizer's advent to the nursery- 
is the forerunner of colics in the baby and even grave nutritional 
disease. Much more trouble to bring up a baby on the bottle than at 
the breast. 

Some women have inverted nipples, or fissured nipples, or 
bifurcated nipples, or the nipples may be sunken or constricted at 
the base, or flat : a tendency to crack may even be manifested dur- 
ing pregnancy. In the last two months of pregnancy if the nipple 
be not well formed, let the patient herself draw out the nipples 
morning and evening with her fingers gently. Brisk manipulation 
may cause uterine contraction. Wash the nipple with Tr. Sapo. 
Vir^ and water once a week, on other days simply water. ^Anoint 
every day with cocoa-butter or albolene. Some authors advise hard- 
ening the nipple with alcohol, alum, and tannic acid, but it is not to 
be recommended. No comipression of the gland by the dress, espe- 
cial care to avoid compression of the nipple. May make a ring of 
cotton or wear a wood nipple shield under the chemise. The 
simpler remedies are the better. If heavy and painful, the breasts 
should be supported by some form of bust supporter sold in the 
stores. For details see Obstetrics for Nurses. 

Examination of the Urine. 

Every three weeks to the seventh month, the urine should be 
examined. After this as often as once in .two weeks, and if there 
are albumin and casts, every day. Seldom can carry this p?lan out. 
At least every two weeks in the last two months of pregnancy. 
Kidneys, the most vulnerable point in the body during pregnancy, 



XOTES ON OBSTETRICS— JUNIOR CLASS. 101 

and it is therefore essential that you know in what condition the}' 
are. The examination should be for albumin, using heat, nitric acid 
and the Picric Acid test, for the specific gravity, sugar, per cent of 
urea and above all, casts. Amount in twenty-four hours also valu- 
able. Albumin occurs in a large per cent of cases, but renal albu- 
min in not over 5%, and this is the most significant. The onset of 
a nephritis may be foretold and its progress checked if you examine 
the urine carefully, and frequently. 

Measiirenient of the Pelvis. 

In this country deformed pelves are very rare in the native born 
women. Of course, the foreigners have the same classes of de- 
formed pelves here as at home. Still, later statistics show that 
milder grades of pelvic contraction do exist, but not so frequently as 
in Germany, Austria and France. Reasons lie in the better hygienic 
surroundings, better food and more of it. We do not meet so many 
abject cases of poverty as in Europe. 

We cannot go into the causes of pelvic deformities here, but I 
wish to emphasize the necessity of making examinations to deter- 
mine the presence of a small pelvis. You may meet with some diffi- 
culty in making the examination, since the minority of even good 
physicians make them. If the patient come to you after lightening 
has occurred, less necessity to examine her pelvis, since the pelvis is 
large enough for that particular head, but the outlet may be con- 
tracted. 

Patient lies lengthAvise in bed, covered with a sheet, with under- 
clothing drawn up on the breast. Can take measurements through 
the sheet, but better to push this down to the hips, always covering 
the pubic hair. Examine the general condition of the patient. 
Length, bones, ends of ribs, curvature of the spine, of the legs, 
shape and size of the head. A tall patient seldom has a contracted 
pelvis. A short woman will be likely to have a pelvis small in all 
its diameters, that is, a generally contracted pelvis. A woman that 
has crooked legs, bow legs, e. g., may have a contracted pelvis. This 
is due usually to rickets, and the enlargement of the ends of the ribs, 
or other epiphyses, points also to rachitis, so also does a large, square 
head. A patient with curvature of the spine can have a distorted 
pelvis. We will return to these points in the discussion of contracted 
pelves. 

There are six measurements which are quite essential : 

1. The distance between the spines of the iHa. Outer lip. 

2. Between the crests of the ilia. Outer lip. 

3. Diameter of Baudelocque ; external conjugate. 

4. Bitrochanteric diameter. 

5. Circumference of the pelvis. 

6. Diagonal conjugate. CD. 



102 NOTES ON OBSTETRICS— JUNIOR CLASS. 

Spines, 26 cm. ; Crests, 29 ; Trochanters, 30 ; Bauclelocque, 20 ; 
Circumference, 90; Diagonal Conjugate, 12^. 

Baudelocque — from under the tip of spine of the last lumbar 
vertebra to the upper anterior part of the pubis. The deductions 
to be made from these findings will be discussed under mechanism 
of labor. 

Posterior branch of the pelvimeter to be placed in the depression 
made by this process. The Rhomboid of Michaelis, a beautiful dia- 
mond shaped depression on the posterior aspect of the pelvis, formed 
by the dimples of the posterior inferior spines of the ossa innomi- 
nata, the point where the glutei come together, and the groove of 
the spine. Seen on beautiful statues, e. g., the Capitoline Venus. 
Modern sculptors emphasize the hollow. The depression for the 
calipers is usually at the apex of the rhomboid, but may be a little 
under it. 

The use of this landmark in the diseases of the pelvic bones will 
be discussed under the pathology of labor. 

The circumference is taken so that the tape lies between the 
crests and the trochanters on each side and in a plane perpendicular 
to long axis of body. 

The diagonal conjugate is the distance from the under edge of 
the pubis to the promontory of the sacrum. It must be taken by the 
two fingers passed into the vagina, so as to touch the promontory, 
and then pressed up against the lig. arcuatum. 

The Importance of Pelvic Measurements. 

Taken early in pregnancy we can induce labor for a contracted 
pelvis. Second, we can know what kind of deformity we have to deal 
with and can prepare for the same. Often called in consultation to 
a case where some bad position of the fetus, which could have been 
prevented had the doctor recognized that he had a deformed pelvis to 
deal with, and thus baby's or mother's life saved. Again, during 
labor certain anomaHes can only be explained after a careful exami- 
nation of the pelvis. 

Engagement of the Nurse. 

This is an important duty. After you have made your diagnosis 
as to the time of labor, you engage the nurse for the labor. Better 
do this yourself unless patient has some preference in the matter. 
If you know that the nurse recommended is a good one, engage her, 
if not, exert your authority in the matter. 

Qualifications of a nurse: — She should be strong, neat, sympa- 
thetic, a graduate of a training school where she got obstetric train- 
ing, and she should have had some experience in private practice. 
She should be agreeable to the patient, above all loyal to you. She 
should be willing to carry out instructions to the letter, and be famil- 



NOTES ON OBSTETRICS— JUNIOR CLASS. 103 

iar with your methods. She should carry out all instructions and not 
be a tale bearer. Poor nurses often quarrel with the servants, and 
may cause discord in the house. A nurse should be a woman of 
tact. 

Diagnosis of Position and Presentation. 

The position of the fetus during pregnancy varies a great 
deal. From its mode of growth it has a flexed position. In the 
middle of pregnancy there is no constancy in the fetus's position at 
all, but toward the end it tends to become more fixed. After the 
head has entered the pelvis there is usually no more change in posi- 
tion, but I have found that the head sometimes leaves the pelvis and 
re-enters in a different position. In multiparae, however, the posi- 
tion changes frequently in the last weeks. Rules for determining 
position of child are the same as during labor. 

Four (4) principal movements : 

1. What is the ovoid — longitudinal or transverse? 

2. What is over the pelvis — head or breech ? 

3. What is in the fundus — breech and feet or head? 

4. Toward which side is the back, right or left? 
Diagnosis may be controlled by the position of the heart tones. 
Not necessary to make internal examination. 

If you find the head over the inlet in the last few weeks, you 
may make a gentle attempt to press the head into the inlet. This 
is called Miiller's procedure, and its object is to see if the head will 
fit the pelvis. Examine your patient in the last week before labor 
and determine if the child lies aright. These points will be enlarged 
during consideration of the conduct of labor. 

List of Articles Needed for Labor. 

This will depend on the purse of the patient. Following is a list 
the writer gives his patients : 

Two hand basins of granite ware. 

Two hand brushes, wood backs. 

One new two-quart douche bag. 

Rubber sheeting enough to cover the bed and a piece a yard 
square. 

Two pounds J. & J.'s absorbent cotton. 

Five yards J. & J.'s borated gauze. 

One hundred bichloride of mercury tablets — P. D. & Co.'s. 

Four ounces lysol. 

Four ounces of boric acid crystals.. 

One ounce of camphorated oil. 

The gauze is used for making the pads for the labor and the 
napkins to be used to catch the lochia. 

hs a general rule among the poorer classes you will have to 



104 NOTES ON OBSTETRICS— JUNIOR CLASS. 

bring most of the antiseptics, gauze, cotton, etc., yourself, or pre- 
scribe them after you get to the house. Do not use the "Aseptic" 
gauze that is put on the market. Always antiseptic gauze. 

1. Give the patient a few instructions about the advent of labor, 
what to expect and what to watch for. What she should do before 
you come, in case she has no nurse. 

2. You ought to speak to the nurse if she be a stranger to your 
methods, telling her what you want her to do and what not to do. 

3. It is well to visit the patient in the last 10 days before labor to 
see if child lies in proper position, to make the arrangements about 
the confinement room, bed, etc. 

4. In general you treat an obstetric case with the same care that 
you would give a major surgical case. 



PHYSIOLOGY OF LABOR. 
Deiinitioii and Clinical Course. 

Labor is that function of the female organism by which the prod- 
uct of conception is extruded from the uterus through the vagina 
into the outside world, the regressive metamorphosis of the genitals 
started and the secretion of milk inaugurated. 

Thus there are three essential points in the definition. This defi- 
nition excludes the extraction of the fetus by any other passage, as 
in Caesarian Section. 

Abortion is the interruption of pregnancy before the fetus is 
viable. 

Premature Labor is the interruption of pregnancy after the fetus 
is viable, but before term. 

Miscarriage is a term used by the laity to signify the occurrence 
of a premature interruption of the pregnancy at any time. 

Labor is a normal function of the female. It is so intricate, 
however, that a great many irregularities may mark the course. 
The altered hygienic surroundings, the tendency to laziness, the evils 
of dress, of living, occupation, heredity, evolution of the head, i. e., 
increased size of the cranium due to the increased mental capacities 
of the race), chronic endometritis, salpingitis, etc., all tend to pro- 
duce conditions which influence the course of labor and may make it 
absolutely impossible in a given case, or make it fraught with great 
or even fatal danger. 

We thus must divide cases into two groups : 

1. Normal labor or Eutocia. 

2. Abnormal (pathological) labor or Dystocia. 

As a matter of fact a really normal labor without the slightest 
irregularity is rare ; almost always there is some small point that is 
peculiar, although it may not affect the general course of the labor 
and the case may end favorably for mother and child. In general 
we call those cases normal where we do not have to interfere, where 
the patient expels the child and placenta herself, and she and the 
child live. The specific boundaries of Eutocia and Dystocia we will 
come to in the course of the lectures. 

The expulsion of the ovum is brought about by uterine contrac- 
tions, but there are other factors involved. In considering the 
mechanism of labor, we have to consider three factors : 

Powers ; i. e., uterus, abdominal muscles, vagina, etc. 

Passages ; i. e., pelvis, soft parts. 

Passengers ; i. e., the fetus and secundines. 



106 NOTES ON OBSTETRICS— JUNIOR CLASS. 

When the relations of the three to each other are normal, we 
speak of Eutocia — when otherwise, Dystocia. 

When we consider the conduct of labor, we have to add a fourth 
factor, Complications. 

Causes of Labor. 

What brings on labor? Why should a uterus which has carried 
an ovum for so long, suddenly, violently expel it? Nature certainly 
recognizes the right time for the expulsion, i. e., 

1. The fetus must not be too laige, and 

2. It must be so far developed as to be able to continue its extra 
uterine existence. 

How this point is determined, we do not know. There are nu- 
merous theories as to the exciting causes of labor. A few of the 
most important may be of interest, but they have a further interest 
in that we may want to induce labor ourselves, and a good general 
plan is to imitate nature ; it is surprising how^ much one can learn 
from nature, and how, by following the path nature takes, cases can 
be brought to a happy termination. 

1. Maternal Causes: — 

(a) (i) Pressure of the presenting part on the lower uterine 
segment, on the great cervical ganglion or its branches. This is an 
old theory and is supported by many facts ; e. g., that labor takes 
place when the head is in the pelvis for any time. (2) In contracted 
pelvis, where the pressure is earlier, labor occurs earlier. (3) Argu- 
ment from analogy, material in the rectum or bladder. 

This theory does not explain the labor in transverse presenta- 
tion or in breech presentation where no part engages. 

(b) Excessive distension of the uterine wall. This holds good 
only in pathologic cases ; hydramnion, multiple pregnancy. 

(c) Thrombosis of the placental vessels in the latter weeks of 
pregnancy. Leopold says this causes increase of CO^ in the blood 
of the uterus, and therefore contractions. ]\Iust explain the throm- 
bosis, and again this is not constant. 

(d) Fatty degeneration of the deciduae which makes the fetus 
a foreign body. Not constant. 

(e) Menstrual inflneiice. Said that every month a reflex goes 
from ovary to uterus, causing menses in non-pregnant and the con- 
gestion during pregnancy. May cause small hemorrhage which 
brings on labor. This theory presupposes too much : 

1. That there is some constant relation of ovulation to men- 

struation. 

2. That ovulation is a monthly occurrence. 

3. That it takes place during pregnancy. 

4. That the tenth month is particularly disposed. 



NOTES ON OBSTETRICS— JUNIOR CEASS. lOv 

All untenable. Theory not good. Relation of 280 to 28 is acci- 
d-ent. Labor can occur without the ovaries. In some women, par- 
ticularly of a nervous type, there occur during pregnancy, at the 
time of the usual menses, peculiar sensations and manifestations 
which show that some influences are at work. 

Neuralgic pains, especially in the sacro supply-lumbar region, 
insomnia, skin eruptions, increase in .varicosities, vomiting, nausea, 
constipation, decreased urine, sometimes albumin, uterine pain, some- 
times small hemorrhages and tendency to abort are greater at these 
periods. 

(f) TJie Increase in the Irritability of the uterus. We know 
that the uterus contracts from the beginning of pregnancy and also 
that the contractions become stronger and more easily elicited toward 
the end of pregnancy. This increased irritability is due to the great 
increase in the development of the muscular fibres and the nerves 
of the cervical gangHon. When the end of pregnancy is near some 
slight accident may make the contractions stronger and each con- 
traction stimulates the succeeding one till regularity is established. 

IL Fetal Causes. 

The old notion that the fetus delivered itself was held even by 
Hippocrates, who said the fetus got hungry and came out. Numer- 
ous other reasons are given why the fetus w^ished to be released 
from its prison. Hasse says the changes which the circulation under- 
goes in the latter weeks, i. e., narrowing of the ductus arteriosus and 
venosus, cause an increased venosity of the fetal blood. This blood 
causes labor by irritating the uterine wall . 

Brown Sequard has demonstrated that an increase of the amount 
of CO2 in the maternal blood will cause uterine contraction, espe- 
cially if the blood of the uterine sinuses is venous. 

Another author claims that it is lack of oxygen. At any rate, it 
seems that blood not in proper condition may bring- on labor, and 
this may explain some cases. The theory that the fetus urinates 
into the liquor amnii in the latter months, that the urea is decomi- 
posed into ammonia in the uterine muscle which causes contrac- 
tions, has merely historical interest. 

These are the principal theories, of which the most plausible are 
pressure of the presenting part on the lower uterine segment, the 
increased irritability of the uterus and changes in the fetal circula- 
tion. The importance of accident, how^ever, must not be overlooked. 

When everything is ready for labor, the parts softened, the cer- 
vix begun to unfold, the uterine muscle well developed and having 
attained a high degree of irritability, it is easy to see how some 
sHght cause, mechanical or emotional, may suddenly increase the 
uterine contractions. 

As soon as one contraction has occurred, it forms the irritant 
for another, and thus labor is put in progress. Such causes are : 



108 NOTES ON OBSTETRICS— JUNIOR CEASS, 

jolt, running up and down stairs, washing, or lifting a weight, a lit- 
tle diarrhea, or a coitus, or sudden fright, or joy. 

Thus it is impossible to determine the duration of pregnancy, 
since its end may be caused by accident. Still, the fact that labor 
occurs very regularly, about 280 days after the last period, makes 
us believe that there must be some law governing the function. 
What it is, no one knows. 

Can a child be born before the end of the ten lunar months and 
be well developed? Cases have occurred which tend to prove this. 
A woman has given birth to several children at seven months, all 
of which were well developed (quoted by Parvin). 

Again, can pregnancy be prolonged over 280 days? Pregnancy 
cannot go on indefinitely, nor can pregnancy be continued much 
longer than 280 days. A dead fetus retained in the uterus is not 
pregnancy. Pregnancy varies in length in different women and in 
the same woman at different times, ^^^e have already seen how it 
is possible for a woman to reckon eleven lunar months, /. e., when 
the ovum was from the £rst inenstrnation missed, and not from 
the last present. 

Cases are not rare where a woman goes several weeks beyond 
her time. This happens mostly in primiparae, but also in multiparae ; 
usually the child is a male and quite large — one might say, over- 
developed. They have considerable clinical interest. 

A certain number of cases are on record where at the natural 
culmination of pregnancy, pains came on, but labor did not terminate 
— the fetus died and was expelled or extracted weeks, months, or 
even years later. This was called "Missed Labor" by Oldham. Few 
published cases will stand a sharp investigation, but there are real 
cases. Causes are usually, peritonitis chronica ; fibroid tumors of the 
uterus ; obstructions on the part of the fetus or cervix. 

When a woman has a threatened abortion, but the uterine con- 
tractions cease, the ovum dies, and is not expelled for months, we 
speak of ''missed abortion." Expulsion usually occurs at the end of 
the ninth month or earlier. 

CLINICAL COURSE OF LABOR. 

It will be simpler to understand the complicated problems of 
labor if first we get a good idea of the clinical course of labor, that 
is, what you w^ould see when attending a case of labor. 

In most primiparae and in many multiparae, there is a prodromal 
stage of labor. It is not so well marked in the latter, however, and 
labor seems, therefore, to come on suddenly with them. 

These prodromata are : 

I. In the last three weeks Lightening before labor, with its symp- 
toms ; this is often accompanied by a glairy mucous discharge. May 
be absent, especially in multiparae, or unnoticed. 



NOTES ON OBSTETRICS— JUNIOR CLASS. 109 

2. False Pains : In the last weeks the patient is often annoyed 
by uterine contractions that are painful. They occur especially at 
night and lead to the suspicion of beginning labor. 

3. About twenty-four, or forty-eight hours before labor, there is 
a discharge of mucus, often mixed with blood. It is the plug, which 
formerly filled the cervix. The blood comes from the surface left 
bare by the separation of the decidua. It is more or less profuse 
and is important; is called the "Show." 

4. An examination in the last three weeks of pregnancy shows 
the cervix soft, shortened, perhaps completely effaced ; in primi- 
parae the external os opened for one or perhaps two fingers. In 
multiparae the cervix will admit two fingers to the membranes. 

The head is almost always well in the pelvis, in the last two 
days, but is still movable. 

The uterus can be felt to contract under the hand, but the 
contractions do not produce much change in the shape of the uterus. 
They are still normally insensible. They are evoked easily, which 
is a sign of approaching confinement. 

Labor, itself, begins (i) when these contractions become sensible 
to the patient, f. e., painful, and (2), when they are effective in 
dilating the cervix and os ; (3), when they become regular. In some 
cases in the last few weeks of pregnane} there are pains in the 
lower abdomen which come from constipation. They are called 
false pains. Then, again, the uterus may contract and the contrac- 
tion be attended by pain, yet there is no effect on the cervix. These 
are called false pains also, or "dolores presagientes." These pains 
may occur throughout the last two months and become very annoy- 
ing. 

The uterus has a different shape during contraction, i. e., it be- 
comes longer, narrower and more prominent in front. The uterus 
during pregnancy does not assume this shape during contraction, and 
thus one can differentiate even before much dilatation of the cervix 
(vaginal portion). During pregnancy, the uterus simply hardens 
while contracting. 

Labor itself is divided into three stages : 

1. From the beginning of the pains till the os is completely- 
dilated and flush with the vagina, thus forming one continuous canal, 
called the "parturient canal." This is the stage or period of dilata- 
tion. (Eroffnungsperiode). The bag of waters usually ruptures 
at the end of this stage — perhaps during it. First stage does not 
include the rupture of the bag of waters, the time of whose rupture 
is ver}^ variable. 

2. Second stage, from .the end of the first stage till the expulsion 
of the fetus is completed. It is the stage of expulsion. (Austrei- 
bungsperiode.) 

3. Third stage, extends from the delivery of the child till after 



no NOTES ON OBSTETRICS— JUNIOR CLASS. 

the expulsion of the placenta, etc., and contraction and retraction 
are established. It is the period of the afterbirth. (Nachgeburt- 
speriode.) 

In the first stage, recurring regularly about fifteen minutes apart, 
we notice the uterine contractions. These are appreciated by the 
patient as pain and are, therefore, designated by the various races 
from time immemorial as "pains," "dolores," "douleurs," ''Wehen.'' 
No normal labor is painless. Writers of all ages have described 
labor as painful. The Bible mentions it in numerous places. Ac- 
counts of the uncivilized races disprove the claim made by some that 
with them child-bearing is painless. (See Ploss, Das Weib.) 

Still, the severity of the pain varies. Some races, especially the 
uncivilized, have generally easy labors, whereas the highly cultured 
woman has hard, painful labors. This is true to a certain extent in 
our civilized country, the difference between the poor and the rich. 
The pain varies in different women, and the ability to stand pain 
varies in women. 

As the labor progresses, the pains gradually grow stronger. 
Whereas, at first, patient just bends over a little and has a change 
of countenance, after a few hours she may utter a cry. The cry 
is simply one of pain, similar to that of a severe toothache, or in- 
testinal colic. Some women bear the pains better than others, grunt- 
ing merely, while some raise a hue and cry which wakes the whole 
household. During the pain one observes the uterus contract. This 
begins before the pain is felt and ends after the painfulness is over. 
The uterus rises high in the abdomen, increases in diameter ante- 
riorly and posteriorly and decreases laterally, assumes a pear shape, 
at the same time it becomes tender, tense, the ligaments stand out 
sharply. There is a stage of accrement, acme and decrement in each 
pain. 

Under the influence of the uterine contractions : 

1. A larger amount of the serum is forced into the lower uterine 
segment. 

2. The fibres of the lower uterine segment are drawn up into 
the body of the organ. 

3. The liquor amnii is forced downward against the inter- 
nal OS. 

4. The membranes are bulged out through this. 

5. The retraction of the fibres of the lower uterine segment, 
and the membranes being forced out of the cervix like a bladder, 
cause a dilatation of the cervix from above downward, and finally 
a dilatation of the external os. This dilatation of the cervix by the 
bag of waters is a very gentle and efficient one. The whole force 
of the uterus is not used, since the head resting against the lower 
uterine segment divides the cavity into two parts. 



NOTES ON OBSTETRICS— JUNIOR CLASS. Ill 

The resistance at A A diminishes the power of 
a' a", therefore the tension in G is not so great 
as in B. Should the body not press fast to A A', 
allowing the fluid in B to communicate with the 
fluid in G, the tension in G equals that of the 
space of B, occurs often clinically. During a pain 
the tension in B rises, therefore, also of G, but to 
a less degree ; when the pain passes away, the ten- 
sion in both subsides. Thus it is seen how the 
head acts as a ball valve, and makes the gentlest 
possible method to efface and dilate the cervix. 
Compare this to the rough dilatation which would 
occur were there no bag of waters, and the head 

were forced through the cervix by uterine and abdominal forces. 

This happens when the bag of waters ruptures before labor, e. g., 

in primiparae. These are called "Dry Labors" and are usually long, 

tedious and painful. Operative interference is oftener necessary in 

dry labors. 

We have used two terms which need explanation — effacement and 

dilatation of the cervix. At the beginning of labor, the cervix is 

shaped thus, 



It is drawn up into the body of the uterus and dilated from above 
downward until the external os remains like this. 



This is effacement of the cervix. 



112 NOTES ON OBSTETRICS— JUNIOR CLASS. 

After this is complete or nearly so the external os dilates (by the 
bag of waters, or the presenting fetal part projecting through it), 
until it is large enough to allow the child to pass. This is dilatation 
of the OS. When these processes are completed the parts look like 
this: 



The edge of the cervix is drawn high up and cannot usually be 
reached by the finger, the external os is flush with the vagina. 

The bag of waters projects through like a big watch crystal. 
The first stage is now complete and the bag of waters usually rup- 
tures, but may not, or may have already ruptured. If the child is 
born vv^ith the bag of waters unruptured, its head is covered by the 
membranes, which are called a "caul." The rupture of the bag of 
waters usually takes place at the height of a pain and is usually 
central, when the waters come with a gush. Or the rupture may 
take place high up and the waters dribble away at each pain. Some- 
times an accumulation of fluid between the two membranes occurs 
and the chorion ruptures while the amnion remains intact. Thus we 
seem to have two bags of water. 

At first the pains are an hour or 30 minutes apart. Generally 
irregular both as to time and severity. When the labor is well 
started they are 5 to 10 minutes, apart, later 3 minutes ; seldom more 
frequent than this. In the first stage, the pains are described as 
grinding, or like a severe, general, intestinal colic. They often seem 
to come in pairs, a mild one followed by a severe one. They last 
30 to 90 seconds, or longer. This varies in different women, diflfer- 
ent labors, and different times of one labor. May subside and re- 
commence after hours or days (rare). Patient is cheerful between 
pains, or may doze. 

After the rupture of the bag of waters there is generally a short 
pause in the pains. The uterus needs time to accommodate itself 
to the diminished size of its cavity, for the reimposition of its muscu- 
lar lamellae. There may be a few drops of blood. 

Coincidently with these changes in the cervix the fetal body has 
descended lower into the pelvis, the bag of waters, or the head 
contained in the lower uterine segment distends the vagina and may 



NOTES ON OBSTETRICS— JUNIOR CLASS. 113 

reach the perineum. It presses on the nerves in the rectum and out- 
let of the pelvis and patient feels like bearing down as if at stool. 

The Second Stage Begins. 

Now the pains become stronger and more frequent, every three 
to two minutes, and the patient utters a pecuHar cry. It resembles 
that of a patient having a hard bowel movement ; she holds her breath 
and presses down, usually taking some object to pull on and pressing 
her feet against the foot of the bed. 

Owing to the pressure of the head on the sacral and obturator 
nerves as they go out of the pelvis, the patient complains of radiating 
pains in the legs and to the back. 

In general, the patient is more hopeful, since she can help and 
feels that there is some progress in the labor; whereas, in the first 
stage, all she had to do was to bear the pain. 

During the contraction the uterus gets very hard, the patient uses 
the abdominal muscles, gets turgid in the face, beads of sweat ap- 
pear on the brow, she is in a high state of nervous and muscular ex- 
citement. 

The head comes down and bulges out the perineum. The bulg- 
ing begins from behind. Patient may have defecation now. The 
anus is soon everted and one can see its anterior wall. After each 
pain the perineal tumor recedes, but during each pain it increases. 
Soon the wrinkled scalp can be seen between the labia during a 
pain. After a few more pains a larger segment of the head be- 
comes visible. Under great muscular exertion the head is finally ex- 
pelled. The occiput comes first, from under the pubis, and finally 
the forehead, face and chin come over the perineum. After this 
there is a pause, of a few minutes, when the pains are renewed, the 
shoulders are delivered, and then generally the trunk, in one long, 
hard, expulsive pain. The child gasps, lying between the thighs of 
the mother, and soon cries vigorously. 

A little blood and the rest of the liquor amnii and the ends of 
the membranes are now discharged. The uterus contracts down into 
a ball. The patient feels much relieved. She may have a chill now, 
but this is physiological, since there is no rise of temperature. It is 
the attempt of nature to re-establish the circulation after the loss of 
fetal circulation ; may occur after placenta is expelled. Is not con- 
stant. 

The Second- period is nozu ended: the third begins. 

After from five to twenty minutes, devoted to rearrangement of 
the muscular lamellae, the uterus begins to contract again. Some 
blood usually appears externally, with the first pain. The uterus 
lying as a somewhat relaxed, slightly flattened body, the size of a 
cocoanut, during a pain becomes smaller, harder and globular. Soon 



114 NOTES ON OBSTETRICS— JUNIOR CLASS. 

it rises high in the abdomen, usually off to one side (mostly the 
right), while below, over the pubis, the abdomen feels soft and 
boggy. At the same time the cord advances a few inches from the 
vulva. These signs indicate that the placenta has loosened from the 
uterine wall, and has descended into the lower uterine segment and 
upper part of the vagina. At intervals of four to five minutes the 
uterus contracts — afterpains. When the placenta is in the uterus 
the organ is large and globular. When the placenta has been forced 
from its bed into the lower uterine segment and upper vagina, it as- 
sumes a flattened pear shape. The flattening is from before back- 
ward and the fundus is sharp. On the anterior or posterior surface 
there is often a broad, shallow dimple to be felt (the site of the 
placenta). After a few uterine contractions, or if blood accumu- 
lates in the uterus, the shape again becomes more globular. The 
triangular shape of the uterus is another evidence that the placenta 
has left its cavity. 

After a period (if the patient is left alone), varying from fif- 
teen minutes to three hours or longer, the placenta is spontaneously 
expelled by the combined efforts of the abdominal muscles and the 
uterus. Generally, the doctor does not wait for this termination, but 
completes the process himself. The placenta is usually inverted like 
an umbrella, and draws the membranes after it, peeling them off the 
uterine wall (Schultze's method). Sometimes the placenta slides 
out without doubling up. The lower segment appears first (Dun- 
can's method). With the afterbirth a less or greater quantity of 
blood is discharged. Now the uterus contracts down into a hard 
lump in the inlet of the pelvis, extending to the navel. It is of the 
size of a fetal head. 

Name six periods during a normal labor when a woman can 
have hemorrhage. 

The third stage has ended. The Pnerperium begins. 

The uterine contraction, the most prominent symptom in labor, 
deserves more consideration. 

The characters of uterine contractions are : 

1. They are involuntary. Woman has no control over them, 
but some mental emotion may cause a temporary cessation, e. g., 
abrupt entrance of a stranger. 

2. They are said to he peristaltic. From fundus to the cervix. 
Observations in animals confirm this, but human uterus not so simi- 
lar to animal uterus. Ahlfeld, in numerous Caesarean Sections could 
observe no peristalsis. 

3. They are intermittent, i. e., they recur after certain pauses. 
Object of intermittence is to help the circulation of the parts ; during 
the uterine systole, little blood in the parts ; during the diastole, full 
of blood. The contraction also forces the blood into the cervix, in- 
creasing its succulence and so-called vital dilatation. In cases where 



NOTES ON OBSTETRICS— JUNIOR CLASS. 115 

the uterus is trequently irritated or there is some obstruction to 
labor, the contractions become tonic with no relaxation. Then no 
fluid is exuded, the vagina becomes hot, dry and red. Second ob- 
ject is, to allow the fetus a change of blood; danger to fetus from 
tetanus uteri, lies in asphyxia. 

4. They are rhythmical, having three phases, increment, acme, 
decrement. The increment is longer than the acme and the decre- 
ment. Acme a "few seconds. The whole contraction lasts about one 
minute, but this varies very much at different stages of the labor. 
Often a little pain will precede a stronger one. 

5. They are painful. 

Before labor has actively begun they are called dolores pre- 
sagientes. When the os is beginning to dilate, they become quite 
painful — are called dolores preparantes. They seem to have their 
seat in different places, some cases in the back, others in the pelvis, 
again in the abdomen. 

The first pains of labor are felt m the back, near the kidneys, and 
are called by the French women, "pains of the kidneys.'' They may 
be felt only as a feeling of weakness and the patient supports her 
back. Later the pains are felt more in the pelvis. In the first stage 
the pain is due to the pressure of the presenting part on the nerves 
of the cervix, the stretching of the same due to the dilatation of the 
OS by the presenting part, or, some authors say, that the compression 
of the nerves in the wall of the uterus is causative. 

The pains in the small of the back are due to radiation, such 
as is common in pelvic neuralgias. The nerves involved are the 
sacral and lumbar plexuses. The pains caused by the dilatation of 
the last fibres of the cervix are particularly painful (sometimes a 
slight amount of blood may show itself, indicating a tear in the 
cervix) . 

When the head gets down into the vagina and begins to press 
on the perineum, the pain is due to the stretching of these parts, and 
are spoken of as tearing. Dolores concassantes. 

The patient now bears down and the pain cry is altered. She 
does not complain so much but helps the labor along by pressing 
down with the abdominal muscles, AVhen the head goes through 
the vulva the greatest anguish is felt, the patient feeling as if she 
were torn open. The pain may be so great that the patient faints 
(but this is rare), or is temporarily insane, due to the stretching 
and tearing of the vulva. 

These pains are called dolores ad partum. After the birth of the 
child, the uterine contractions are called afterpains, or dolores ad 
secundum partum. They usually are not so severe as the others, 
but in some patients the}^ are very painful. In the puerperium they 
may be so painful as to require treatment, particularly in multi- 
parae. 



116 NOTES ON OBSTETRICS— JUNIOR CLASS. 

The Pozi'er of a Uterine Contraction. 

Duncan tried to measure it by testing the resisting power of the 
membranes attached to the placenta. The force necessary to rupture 
them varies greatly. Schatz, with an instrument, the Tocodynamo- 
meter (a rubber bag, half-filled with water, in the uterus, connected 
with a manometer), found the force of the uterus varies from 17 
to 55 pounds, and that the power of the abdominal muscles was 
about the same. 

The powers of labor alone may crush in a baby's head or fracture 
its bones. Sometimes when the doctor's hand is in the uterus, the 
pain squeezes it so that it cannot move, and it loses power, may be 
very pamful. Sometimes the pains are so strong that the baby is 
ejected with force from the vulva (rare). Probably the usual 
amount of force needed for delivery does not exceed 20 lbs. 

The Plastic Changes of the Fetns During Labor. 

Owing to the pressure exerted by the maternal passages during 
labor, the head is altered in shape. The chin is pressed to the 
sternum, the face is flattened, the forehead also, while the occiput 
is made pointed. These changes are marked the more resistance is 
met. Should the face or other part be delivered first, the head under- 
goes corresponding changes. On that part of the head least sub- 
jected to pressure there appears, in long labors, a soft, boggy, cir- 
cumscribed tumor. In head presentation this tumor is on one of the 
parietal bones. It is due to the fact that the pressure of the uterus 
upon the whole body of the fetus is greater than that on the small 
part lying over the internal os, or in the vagina. As a result, the 
blood in the veins cannot return from this part, there is venous con- 
gestion and exudation of serum. After the bag of waters has rup- 
tured, this is especially likely to occur, but it may occur before this 
(rare). 

After the head has reached the vulvar orifice, if arrested here, the 
vulva offers a circle of resistance and the same condition occurs, a 
new tumor being formed on the fetal head. 

This is called the Caput Siiccedaneuni. The tumor takes place in 
and under the scalp — not under the periosteum. It is, therefore, 
movable on the skull. It is soft and boggy, allowing the finger to 
make depressions in it. There are often small hemorrhages in the 
caput succedaneum and these may even be found under the perios- 
teum. 

The caput succedaneum is of importance in the post partum di- 
agnosis of the position and presentation of the fetus, and also to de- 
termine when it is necessary to terminate a given labor. One must 
distinguish between caput succedaneum and cephalhematoma, which 
is an accumulation of blood under the periosteum. 



NOTES ON OBSTETRICS— JUNIOR CLASS. 117 

Differential Diagnosis Betzvcen the Tzvo. 
Caput S^necedanciun. Cephalhematoma. 

Is present at birth. JMa}- not appear till few hours 
Soft, boggy, pits on pressure. after birth. 

Not well circumscribed. Soft, elastic, does not pit. 

Dark, reddish, sometimes purple, Sharply circumscribed. 

ecchymotic. Normal skin over it. 

Passes over sutures. Limited by the sutures to the in- 
Movable on skull. dividual bones. 

No prominent edge. Solid — can't be moved. 

Disappears in a few hours, or a Edge a prominent ridge. 

day. Lasts several weeks. 

Gets smaller after birth. May appear first after birth, and 
May sink to most dependant part even grow larger. 

of head. , Remains localized at first site. 

Maternal Changes the Result of Labor. 

It is not to be expected that a process requiring so much muscu- 
lar exercise, such anxiety, and accompanied by such pain, can be 
without a strong influence on the maternal organism. The patient 
eats little, is usually restless and does not sleep during labor, may 
even have had pain at night and no sleep for a week, and this makes 
her exhausted. A labor lasting a few days leaves the patient weak, 
completely tired out. This depends on the length of the labor and 
the strength of the woman in the first place. 

Duration of labor varies much in time, which is true also of the 
same woman in different labors. In the uncivilized races labor is 
somewhat shorter. Said that some Indian women, while the tribe 
is on the march, when they feel the pains of. labor coming on, go off 
to the side in the underbrush, have the child, and, after expressing 
the afterbirth, hurry to catch up with the rest of the tribe. 

In primiparae labors are longer than multiparae ; labor is shorter 
in warm climates, also during summer, in poor, hard-working women 
than in the rich ; therefore, shorter in the country than in the city. 

The size of the fetus has a great deal to do with it, a large 
fetus, long labor. In young, strong primiparae, easier labor than in 
old primiparae. Old primiparae, average 27 hours, but one is often 
surprised to see an easy labor in a primiparous patient over 40 years 
old. Labor is longer in fat women. Boys harder than girls, because 
they are larger. Primiparae, first stage, 16. hours; second stage, i^ 
to 2 hours ; third stage, varies from a few minutes to several hours. 

Multiparae, first stage, 12 hours; second stage % to ^ hour; 
third stage, variable — from a few minutes to several hours. 

Extremes are not rare — have had cases where labor was com- 



118 NOTES ON OBSTETRICS— JUNIOR CLASS. 

pleted in one hour, even less. Again there are labors which are slow 
from the start, requiring days for completion. 

The majority of labors begin between 9 and 12 P. M.,.and end 
between 12 and 9 A. M. This is not a large majority. The differ- 
ence in the length of labor in primiparae and multiparae is due to 
the dilatation of the cervix and perineum and vulvar orifice, which in 
the latter is accomplished more rapidly, being soft and dilated from 
previous stretching. 

The Temperature during labor goes up a degree, or even some- 
times a degree and a half; depends somewhat on the time of day. 
Higher temperature is usually due to infection. The cause of this 
is increased muscular exertion, but that this alone can cause high 
temperature is very doubtful. Have seen 101° F. in a normal labor. 
Subsided in 12 hours. 

The Pulse increases somewhat during labor, but between the 
pains may be normal. In the second stage, during the severe muscu- 
lar exertion, the pulse rate increases a good deal, but in the third 
stage, if no hemorrhage be present, it is usually normal. Any 
marked increase must put you on your guard against hemorrhage, 
external or internal. Arterial tension is increased till after the third 
stage unless there is hemorrhage. 

The Respirations are increased during the pains, but between 
pains are normal. In the second stage they are more rapid, irregular 
and altered, as described. In the third stage, they are again normal, 
unless there be hemorrhage, when an increase in number, or gasping, 
shortness of breath, persistent yawning, shows you there is some- 
thing wrong. 

The Intestinal Tract; often in the first stage there is vomiting 
and nausea. Old midwives say "sick labors are easy." And some 
truth in it, as the nausea has a tendency to cause relaxation of the 
cervix. Once the custom to give emetics, but practice bad. 

In the second stage, persistent vomiting should be suspected, as 
it is often the sign of great exhaustion. It also points to threatened 
or actual rupture of the uterus. In the third stage, vomiting almost 
never occurs, unless some pathological condition behind it, e. g., 
hemorrhage, ruptured uterus. After a labor is completed there may 
be nausea and vomiting from the anesthetic used, especially true of 
operations. Persistent nausea and vomiting after a severe opera- 
tion must draw your attention — perhaps injury, intra-abdominal 
hemorrhage. 

The Mental Condition of the patient during the first stage usually 
not different than that of a patient suffering pain. May be marked 
by hysterical manifestation in predisposed women. In the second 
stage, especially at the end, the patient may become delirious from 
the pain, but this is rare. Real fainting is also rare, in normal labors. 
Whenever I have seen it, the cause has been hemorrhage or shock. 



NOTES ON OBSTETRICS— JUNIOR CLASS. 119 

In the third stage, the patient usually feels well. Is greatly re- 
lieved after the great suffering and may fall asleep. The patient 
may have chills during the labor. Those occurring after the baby is 
born and after third stage, already mentioned. Due to the exposure 
of the patient, the wet bed, the loss of a source of heat (the fetus), 
to nervousness. Have no significance during the labor, the profuse 
sweating and exposure may cause them. Other patients are hot, 
and throw^ ofif the covers. 

Between pains the patient may sleep or doze ; true also in the 
second stage, but not so common. 

Changes in the Urine. Amount increased noticeably. Frequent 
urination in the first stage, and often the full bladder offers obstacles 
to labor ; therefore, pay attention to bladder. Sometimes in the third 
stage the full bladder may cause hemorrhage and retention of the 
placenta. Bladder may be seen and felt over the pubes. Increase 
of urine due to increased arterial tension. Albuminuria is common, 
30%. White blood cells, red blood cells, and hyaline casts may 
occur in the urine during labor. Increase in NaCl. Said that pep- 
tones may occur. 

The mother loses one-ninth of her weight during labor. This 
is made up of the child, the placenta and membranes, the liquor 
amnii, excretions from the skin, lungs, kidneys, etc., and blood. 
Average 6,564 gms., of which 5,000 the ovum, and balance the 
blood and excrement. These are averages ; fetus 3,200, placenta 500, 
liquor amnii 1,000, blood about 400 gms. 

No labor (normal) is bloodless. A few cases of bloodless labor 
on record, but in these the fetus had been dead a few weeks. The 
amount of blood varies normally in wide limits. In one case of 
labor not over one ounce of blood lost, while sometimes it may reach 
800 gms., and still be normal. Varies with the size of the woman, 
the character of the labor, the medical attendant, and how the third 
stage of labor is conducted. This loss does not affect the woman 
usually. 

During the first stage, there may be a little hemorrhage, when 
labor begins, the show. Second, when the cervix is dilating, from 
little tears, especially toward the end. Some of the hemorrhage 
may come from the vagina or the vulva, especially in primiparae, but 
the greater part comes from the placental site, and this varies in size ; 
therefore, the amount of blood also. A low placental site, more 
hemorrhage. The placenta is sometimes inverted and contains a large 
blood clot, and fluid blood, called the retroplacental haematoma. 

Thus, there are six periods during a normal labor when hemor- 
rhage can occur. 

1. The show^, which may be more or less bloody. 

2. Toward the end of the first stage, when the last fibres of 
the cervix are giving way. 



120 NOTES ON OBSTETRICS— JUNIOR CLASS. 

3. During the delivery of the child, through the vulva, from tears 
of perineum and the outlet. 

4. After the delivery of child, from tears of the parts and pla- 
cental site. 

5. With the delivery of the placenta and in it (3rd stage). 

6. After the delivery of the placenta. 

The Prog)iosis of Labor. 

Labor is physiological in most cases, but too many irregulari- 
ties exist to regard it w^holly in this light. In ideal labor, no deaths 
would occur, but we have not reached this ideal. ^Mortality in a gen- 
eral way is i to 175 cases, including all labors. Due oftenest to the 
most preventable causes, infection and hemorrhage. 

Xinety-six per cent, of all cases are normal, /. c., terminate spon- 
taneously and with good results for the mother and child. This is 
the prognosis quoad vitani. 

The prognosis quoad valitudinem is less good. ]\lany women date 
chronic invalidism from a childbirth. A large number of these cases 
are due not to the childbirth itself, but to infection occurring at the 
time, or injuries inflicted by a rash attendant. 

The prognosis for the child is less good — about 4^ per cent, 
dying in ceph. presentations, 10 per cent, in breech presentations. 

THE ]^IECHAXIS:\I OF LABOR. 

]\Iay be defined as the art and fashion by which the ovum is sep- 
arated from the uterine wall and extruded through the vagina. In 
the study of the mechanism of labor we have to consider, first, the 
Powers ; second, the Passages ; third, the Passengers. After this we 
take up the nervous mechanism, then the various phenomena ob- 
served are explained, first those connected with the preparation of 
the soft parts, then those connected with the propulsion of the fetus, 
then those connected with the separation and expulsion of the after- 
birth. 

The Powers. 

The main power involved is the uterine contraction, but there 
are auxiliary powers, e. g., the pressure of the abdominal muscles, 
the weight of the child, the elastic contraction of the vagina, gravity. 

Uterine Contraction. During contraction the uterus exerts 
pressure on its contents, which, being fluid, suffer the same pressure 
all round. The uterus changes in shape, lengthens, flattens from side 
to side and increases in anterior posterior diameter. This occurs 
when the amount of liquor amnii is small. Should there be a large 
amount of fluid or twins, the form will be more nearly spherical. 



NOTES ON OBSTETRICS— JUNIOR CLASS. 121 

This change in shape of the uterus is the result of several factors : 
(i)' The fetus Hes in the uterus strongly flexed; this is due to the 
embryonal growth of the fetus, not to the fact that the head rests 
on the brim of the pelvis. This curve is marked, like this : 
When the uterus contracts it flattens from side to side, 
which causes an elongation of the axis of the fetus, or ex- 
tension of the spinal column. As a result of this, the 
uterus is stretched by the long axis of the child, at the same time that 
the uterus, contracting, presses on the long axis of the child. The 
combined result is a progression of the lower pole of the child, since 
the upper pole is fixed by the uterine wall. This pressure is called 
the fetal axis pressure. F. A. P. It is claimed that the extension 
and lengthening of the fetus can bring its head to the perineum, but 
there are other factors involved. Schroeder says that there is an 
increase of 6 c. m. in the length of the fetal axis. F. A. P. is ab- 
sent in polyhydramion. 

When the uterus contracts on its contents, it exerts pressure 
equally in all directions (Law of Physics, pressure exerted on a fluid 
is distributed equally in all directions), and returns to the uterine 
wall, having resulted only in an increase of the tension in the uterus. 
This is called General Intra-Uterine Pressure. G.I. U. P. 

General intra-uterine pressure accomplishes : 

( 1 ) The dilatation of the lower uterine segment and the part 
of the cervix which remains. 

(2) It causes also an edema of the cervix and 1. u. s. which 
facilitates the dilatation of these parts, so-called "vital dilatation." 

(3) The formation of the bag of w^aters. 

(4) It helps to expel the fetus. 

(i) General increase in the pressure in the uterus is met by 
resistance all around. The resistance offered by the lower uterine 
segment, however, is less than that of the rest of the uterus ; there- 
fore, lower uterine segment dilates. (2) The 
venous circulation is impeded, w^herefore, there is 
serous exudate, and softening of the parts. (3) 
Naturally, the membrane over the lower part of 
the uterus is forced down into the internal os, and 
thus the bag of w^aters is formed. (4) It also 
helps expel the fetus in this way. The contents 
of the uterus are forced in the direction of least 
resistance, that is, to the internal os. The resultants 
of all the lines of force will be exerted on the body 
A. The resistance met at BB. is the obstacle to 
the passage of the head. This is called the "girdle of resistance." 

The General Intra-Uterine Pressure is always present. Fetal 
Axis Pressure may be absent in hydramnion, or small fetus, or a 
macerated fetus, i. c, the fetus does not "keep a stiff back." 



182 NOTES ON OBSTETRICS— JUNIOR CLASS. 

The Fetal Axis Pressure accomplishes the progression of the 
fetus and to a certain extent the dilatation of the os, when the bag 
of waters is broken. 

Auxiliary Forces: The round ligaments, the uterosacral and broad 
ligaments. The round ligaments begin to be active early in labor ; 
being muscular and part of the uterus, they contract also and serve 
to moor the uterus on the pelvis and to bring it slightly forward 
so that its axis lies parallel with the axis of the inlet. The moor- 
ing of the uterus prevents its too great retraction up over the fetus. 
Another function of the round and broad ligaments is that they in- 
crease the General Intra-Uterine Pressure by pulling on the top of 
the uterus. They thus act as a weight lying on the uterus. The 
uterosacral ligaments pull the cervix downward when it tends to go 
up with the uterus, and backward ; thus keeping the uterine canal in 
the axis of the pelvis. They may also help a little to dilate the 
cervix. 

The Abdominal Pressure: This is the second important force of 
labor, but is really auxiliary, being used in the second stage to 
aid labor, or acting as a reserve store of energy in the event of 
failure of the uterine contractions. During the first stage the abdo- 
men takes little part in the process of labor, but in the second stage 
it is a powerful auxiliary, and may do all the work. 

During a pain the woman closes the glottis and makes a strong 
expiratory effort ; therefore, the diaphragm is forced down, the recti 
are exerted and the muscles of the flanks. There is now an enor- 
mous increase of the intra-abdominal pressure. The intestines, with 
their semi-fluid contents, can be compressed but little and really act 
like fluid, so that the general law applies here also ; pressure exerted 
by the abdomen is transmitted equally in all directions. The uterus, 
therefore, receives less of the force. We have nearly the same con- 
ditions as we have inside the uterus. 

The abdominal pressure, therefore, strengthens the uterine press- 
ure. 

(i) It increases the general intra-uterine pressure. 

(2) It causes a transitory edema of the lower uterine segment 
and vagina, aiding the so-called 'Vital dilatation." Thus, it acts 
very much like the uterine contraction. It accomplishes : 

(3) The expulsion of the fetus in the same manner as the general 
intra-uterine pressure. 

The abdominal muscles are usually suflicient to expel the child 
alone. They are used to greater extent in pathological labor, and 
are very important in preventing the rupture 
of the uterus. The whole uterus is forced 
down upon the pelvic inlet by the abdominal 
muscles. This tends to prevent the uterus 
from retracting over the child and leaving it 



NOTES ON OBSTETRICS— JUNIOR CLASS. 123 

in the stretched lower uterine segment and 
cervix. In the third stage, the abdominal 
pressure may expel the placenta. This oc- 
curs in 14 per cent, of the cases, and only oc- 
curs after the placenta has already been sep- 
arated and lies in the lower uterine segment 
and dilated vagina. 

Gravity. In certain labors the weight of 
the child may be sufficient to deliver it. In 
the position we use in delivery (the patient 
on the back or side), gravity can play very 
little role, but in the crouching position and in 
the sitting posture, when a labor chair is em- 
ployed, gravity certainly has some effect. Occasionally labor occurs 
while the patient is standing, and then the child may fall to the 
ground with considerable force. 

In multiparae gravity produces more effect than in primiparae, 
because in the latter the resistances are greater. 

The Passages. '^ 

The fetus has to pass through a canal whose curve is part of a 
rather small circle (approximately), and which is opposite to thel 
^curve of the long axis of the fetus. Further, the fetus has bent its 
long axis in order to go through the canal. Again, the canal is bony 
in one part, above and below simply muscular and fibrous. One can 
best obtain an idea of how the parturient canal appears from the plate 
of Braune. 

The bony pelvis is important in that it gives form to the soft 
part of the canal, and gives this the curve of the pelvis. 

The Bony Pelvis. Divided into two parts by a ridge sometimes 
called the Linea terminalis. Upper or large pelvis, or false pelvis; 
lower, smaller or true pelvis. Of obstetric interest the false pelvis 
presents : ( i ) Large flaring plates of bone, called the ilia, which form 
supports for the uterus and child during pregnancy and direct it into 
the true pelvis during labor. (2) From its shape and dimensions we 
can form some idea of the size and form of the small or true pelvis ; 
of vital importance in studying labor. 

Three diameters of importance : 

(i) The distance between the spines of the ilia, the Interspinous 
diameter ; in the dried pelvis is 24, in the fresh pelvis 26 c. m. 

(2) The distance between the crests 2"/, in fresh pelvis, 29 c. m., 
called the intercristous diameter. 

(3) The diameter of Baudelocque, or the external conjugate. 
From the last lumbar spine to the top of anterior surface of pubis. 
Measures 20^ on the living. 

Right External Oblique Diameter, 



124 NOTES ON OBSTETRICS— JUNIOR CLASS. 

(i) From the right posterior superior spine of the iUum to the 
left anterior superior spine ; 22y2 c. m. 

Left External Oblique Diameter. 

(2) The left posterior superior spine to the right anterior su- 
perior spine; 22 c. m. Why the difiference? 

The curve of the crests is important, a nicely rounded curve in- 
dicating a normal inlet. 

The true pelvis is not the same throughout its length. It is 
narrow above and narrow below, while between the two points it 
is large and roomy. The shape of the canal changes, too. 

The anterior wall of the true pelvis is short, the posterior high. 
The outlet of the pelvis looks downward and forward, the inlet up- 
ward and forward. The canal of the pelvis describes a curve with 
the concavity forward. Further, the pelvis decreases in width from 
above dow^iward, while its antero-posterior diameter increases. Thus, 
there is a difference in the contour of the pelvis at dififerent parts. 
It is, therefore, best, in order to get an idea of the parts, to study 
the pelvis at various and characteristic levels, or planes. 

I. The Plane of the Inlet; or (the Inlet, the Brim, the Superior 
Strait or Isthmus, or Margin, variously termed), is the plane bounded 
by the Superior Margin of the symphysis in front, the linea innomin- 
ata at the sides, the promontory of the Sacrum behind. 

Shape of this plane is that of a transverse ellipse, on which the 
sacrum intrudes posteriorlv. 



Diameters. 

(a) Sacro-puhic^ antero-posterior or Conjugata Vera C. V., va- 
riously named, is the distance from the middle of the promontory of 
the sacrum to the top of the symphysis pubis. This is the anatomical 
Conjugata Vera, and is a little larger than the true obstetrical con- 
jugate, which, owing to the prominence of the posterior surface of 
the Symphysis, must be measured from promontory of the sacrum 
to a point Yz c. m. below the top of the symphysis. 

It is ^ of a c. m. shorter than the anatomical Conjugata Vera. 
It varies with the development of the pubis. This is the shortest 
diameter of the pelvis and the most important in all respects. Meas- 
ures lie. m. (Obstet. C. V.) 



NOTES ON OBSTETRICS—JUNIOR CLASS. 125 

The Oblique Diameters. 

(b) Quite important, also. Extend from the Sacro-iliac syn- 
chondrosis to the lUo-pubic tubercle of the other side. The ist 
oblique is from the right Sacro-iliac joint to the left tubercle, the 2nd 
oblique from the left to the right, sometimes called the right and left 
oblique, being named from the Sacro-iliac joints. They measure 12 
to 12^ c. m. Right a little longer than the left, because the rectum 
encroaches on the left side, and again the right half of the pelvis is 
flattened sometimes (causes given later). 

Latin names are Diam., Diagonalis, Dextra and Sinistra. 

(c) The longest" diameter is the Transverse Diameter^ i. e., the 
longest distance between the linea terminalis on each side. These 
points usually lie 3 c. m. before the Sacro-iliac joints. 

Average is 13 c. m. in the dried pelvis. In the living this diam- 
eter is encroached on by the ilio-psoas. See IMueller Handbuch, Vol. 
I, pages 78-89. 

II. Wide Pelvic Plane. Sometimes called the i\Iid Plane. Term 
still much used in Operative Obstetrics. Passing through the middle 
of the posterior surface of the symphysis pubis and the junction of 
the 2nd and 3rd vertebrae of the Sacrum, and is on a level with the 
highest parts of the acetabula. It is the widest part of the pelvis, is 
sometimes called the "Excavation," and has a very irregularly 
ovoidal shape with the long axis antero-posteriorly. 



Diameters. Antero-posterior (not the Conjugata A^ra), is 13^ 
to 14 c. m. Transverse 12 c. m. 

Oblique diameters which run from the upper edge of the Great 
Sacro-Sciatic foramen to the upper border of the obturator foramen 
of the other side and are 13 to 13^ c. m. 

The lateral diameters are encroached upon by the Obturator in- 
ternus and the Pyriformis, but not very much. 

III. The Narrow Pelvic Plane, passes through the apex of the 
pubic arch, the tips of the spines of the Ischii and the tip of the 
Sacrum. This, is the narrowest pelvic plane, but not the site of the 
contractures of the pelvis, except in a certain type called "funnel- 
shaped pelvis." It is nearly circular and has a diameter of about 
II cm. The distance between the two ischiatic spines is 10^ c. m. 
Important line to remember, since the descent of the head is de- 
termined from this line. 



126 NOTES ON OBSTETRICS— JUNIOR CLASS. 

IV. Plane of Outlet. Passes through the arch of the pubis, the 
tuberosities, the rami of the pubes and ischia, the great sacro-sciatic 
Hgaments and the tip of the coccyx. This is really two planes, bent 
one on the other at the tuberosities, but during labor the head pushes 
down the coccyx and brings the two planes nearly into one continu- 
ous line. This plane is not constant at its posterior part, since, owing 
to the distensibility of the ligaments, its posterior part can be much 
increased in size. 

Antero-posterior Diameter — 9J/2 cm., but which can be increased 
2 or 2^ c. m. Transverse diameter, 11 c. m. ; cannot increase in 
size, since it is between the two tuberosities of the ischia. 

V. Another Plane — more arbitrary than the others, called the 
2nd parallel plane, from under the edge of the symphysis, parallel to 
inlet. Very wide plane and not encroached on by muscle. A line 
connecting the centers of all these planes describes a curve, with its 
concavity anteriorly, which, if continued upward, would strike the 
navel ; it is called the Axis of the Pelvis — or line of Direction, or the 
Curve of Carus. It is the center (about) of the path followed by the 
head in its progress. 

An important measurement, is the distance from the under sur- 
face of the Ligamentum Arcuatum to the tip of the promontory of the 
Sacrum, called the Conjugata DiagonaUs. It is important in that it 
enables us to determine the Conjugata Vera, since we have hardly 
any other way of doing it. 

To get to the Conjugata Vera directly is very difficult and un- 
certain. Conjugata Diagonalis, or C. D., is about 12^ c. m. In a 
normal pelvis deduct i^ cm. to find the Conjugata Vera, in rachitic, 
deduct 2 c m. When you feel that the symphysis is too high, you 
must deduct more. The angle the pelvis makes with the inlet must 
also be considered in making the estimate. 

Another important measurement is the External Conjugate, or 
the Diameter of Baudelocque. This is measured from the depression 
below the spinous process of the last lumbar vertebra to the top of 
the symphysis. It is 205^ c m., from which deduct 9^ c m., to get 
the Conjugata Vera. This measurement is quite uncertain, as the 
Sacrum may be more or less thick. 

Hodge, of Philadelphia, to whom we owe a great deal in obstet- 
rics, from the study of the pelvis by means of plaster casts, drew a 
plane perpendicular to the inlet and passing transversely through 
the ischiatic spines. Together with the muscles and fasciae of the 
pelvic floor, two inclined planes resulted, one leading downward and 
forward, the second, downward and backward, so that any body 
striking these planes, if anterior, would be allowed to slip under the 
pubis ; if posterior, toward the sacrum. These two planes are im- 
portant in the study of labor. They are called inclined planes of 
Hodge. 



NOTES ON OBSTETRICS— JUNIOR CEASS. 127 

The Inlet makes an angle with the horizon of 55 to 60 degrees. 
This varies with the closeness of the knees and the amount of rota- 
tion, being increased with abduction and outward rotation. This is 
called the Pelvic Inclination. Formerly believed to have great bear- 
ing on Alechanism of labor, but now not so. Varies from 40 to 100 
degrees, even while standing. When patient is lying horizontally it 
is about 25 degrees below horizontal line. When patient lies flat, the 
pubis and the anterior superior spine ought to be in a horizontal 
plane. This is a good method of determining a normal pelvic inclina- 
tion. 

In placing a dry pelvis at the proper angle to the horizontal, see 
that the Anterior Superior Spines and the pubic tubercles are in a 
vertical plane and that the acetabular notch looks directly down- 
ward. 

The angle which the symphysis makes with the plane of the 
inlet is 100 degrees, but this varies, being less in a flat rachitic pel- 
vis. 

The Line of Direction of a w^oman standing in the military atti- 
tude, with the shoulders thrown back, passes through the atlas, the 
6th Cervical, the 9th Dorsal, and the 3rd Sacral vertebrae. When 
the shoulders and head are allowed to fall forward the line falls 
in front of the sacrum. To counteract this, the pelvis is projected 
forw^ard, the thighs extended. In certain anomalies of the spine, e. 
g.. Pott's Disease, the displacement of the Line of Direction plays a 
part in the production of the deformed pelvis. 

The pelvis of a new-born child is long, narrow, converges from 
above downward. The sacrum is long, the bodies do not project 
from the wings, the wings are short and the antero-posterior diam- 
eter is long, the transverse short, high promontory, not marked. 
There is very little difference in the male and female pelves of new- 
born children. Highly important is to study the causes which bring 
about the adult form of the pelvis. In general, two causes : 

1. The inherent property of growth of the bones. This is shown 
particularly by the excessive development of the wings of the sacrum, 
in girls, and also the growth of the pelvic bones. 

2. Mechanical factors, of which the most important is the body 
pressure. 

The three bones of the pelvis are put together so that the sacrum 
does not act like a w^edge, or keystone, but is movable, so that it can 
sink down between the two innominate bones. 

In the growing child the line of direction 
falls through a point somewhat anterior to 
the sacrum. This causes pressure to be ex- 
erted on the 1st sacral vertebra. The lower 
end of the sacrum is prevented from going 
backward by the strong sacro-sciatic Hga- 



128 NOTES ON OBSTETRICS— JUNIOR CLASS. 

ments. Therefore, the sacrum is bent on itself at the 3rd sacral verte- 
bra. There is a tendency also for the sacrum to increase its curve 
laterally, but this is counteracted by the projection of the bodies of 
:he vertebrae downward and forward. 

The body pressure also forces the whole sacrum and, of course, 
the promontory, more into the pelvis ; when the sacrum goes down, it 
puts the ilio-sacral ligam.ents on the stretch and gives the posterior 
iliac spines the tendency to approach each other. This would be at- 
tended with a separation of the symphysis were this joint loose. Let 
us call this tendency of the innominate bones to separate at the 
pubis, because of the ilio sacral ligaments tugging at the posterior 
spines, "transverse tension." A marked tension posteriorly with soft 
bones, but fast symphysis, would result in the approach of the sym- 
physis to the promontory. But this is counteracted by the pressure 
of the heads of the femora in the acetabula, which forces the bones 
upward and inward. Let us call this pressure ^^ lateral pressure." 

A harmonious operation of all these three mechanical factors 
causes the pelvis to assume the beautiful oval shape we know. All 
the deformities can be referred back to the anomalies of growth or 
faulty or insufficient action of one or more of them, e. g., in con- 
genital split pelvis (where no union exists in the symphysis), the 
ends of the pubic bones are widely separated from each other, show- 
ing the effect of transverse tension with mild or absent lateral press- 
ure. 

In cases where the patient walked late in childhood, or not at all, 
the "lateral pressure" falls away and the pelvis is under the influence 
of the transverse tension. It, therefore, flattens out, the symphysis 
coming nearer the promontory, and we get the flat pelvis, which is 
usually rachitic. 

The development of the internal genitalia has a decided influence 
on the development of the pelvis. In congenital atrophy of the 
uterus, or infantile uterus, the pelvis does not develop so well, re- 
taining more or less the infantile form. In a pelvis in Bonn the 
diameters are excessively large, the patient having had a double 
uterus, showing the action of the opposite condition. 

The inherent tendency of the growth of the bones must not be 
overlooked, /. e., the lateral growth of the sacrum and of the rami 
pubis. These would tend to increase the transverse tension. In some 
cases one side of the sacrum does not grow, then we have the irreg- 
ularly contracted or Naegele pelvis. 

In-fluence of Raee, IndividuaJs. on the Pelvis. 

A perfectly symmetrical pelvis is a great rarety. Almost always 
some irregularity. Tramond, of Paris, says that 1/5000 is perfectly 
svmmetrical. 



NOTES ON OBSTETRICS— JUNIOR CLASS. 129 

Regarding Race. There are in general four forms : 
I. A transverse ellipse 
II. A heart-shaped pelvis 

III. A round pelvis 

IV. An antero-posterior ellipse 

The first characterizes the European women, and is possibly due 
to the fact that walking later than the savage tribes, her transverse 
tension is not so easily counteracted by the lateral pressure. The sec- 
ond form also occurs in the Caucasian race. The round pelvis in 
African negresses, and to a certain extent in the Bush women of 
Australia and the North American Indian, in whom the antero- 
posterior ellipse may also be found. English women have large 
pelves, while Jewish women have small pelves : Irish women have 
also large pelves, Germans also, but the French are likely to have 
small. Pelves with the longest transverse diameters are found in the 
English and North German w^omen. 

The environment of the patient has a great deal to do with it. 
Small pelves are rare in this country, except among the foreign-born 
population. 

ANATOMY OF THE PELVIS. 

Soft Parts : The inlet of the pelvis is encroached on by the ilio- 
psoas on each side, about i^ c. m. Posteriorly on the left side is 
the rectum. This is an obstruction only when filled. This is not 
a rare cause of dystocia, therefore take the hint. 

The mid-plane is encroached on by the obturator internus, and 
posteriorly by the pyriformis, very slightly, however. The nerves 
in the pelvis make no obstruction to labor, but the pressure which 
they undergo is the cause of the neuralgic pains running down the 
leg, and up the back. The peritoneum and the fat in the pelvis count 
very little in the general configuration of the parturient canal. Dr. 
Hodge took some plaster casts and proved this. 

What interests us most is the so-called pelz/ic floor. The pelvic 
floor consists of that portion of the soft parts which fills out the 
irregularly-shaped outlet of the pelvis. 

A great many parts enter into its formation, the pelvic fascia, the 
coccygeus and levator ani muscles, the constrictor cunni, the deep 
transverse and superficial transverse perinei muscles, fat and the or- 
gans, rectum, vagina and bladder. 

The pelvis may be said to be bounded below by a diaphragm, the 
pelvic diaphragm, similar to the diaphragm separating the chest from 
the abdomen. This diaphragm is made up of the levator ani, and 



130 NOTES ON OBSTETRICS— JUNIOR CLASS. 

the coccygeus and the pelvic fascia, some above and some below this. 
It is perforated by three openings, the rectum, the vagina and the 
urethra, besides by numerous vessels and nerves. 

The diaphragm is attached anteriorly to the posterior surface of 
the rami of the pubis, leaving a space 2^ c. m. wide behind pubis, 
which is not complete. It extends across the opening of the obtura- 
tor foramen, from which it is separated by the obturator internus 
muscle, to which it is attached by a fibrous band called the white line. 
It reaches the inside of the ischium about the level of the spine, to 
which it is attached also ; thus far it is made up of the levator ani, 
now the coccygeus begins, and the posterior portion of the pelvic 
diaphragm is made up of this muscle, which extends across the great 
sciatic notch and spreads out over the coccyx. 

The space of the great sciatic notch is filled with connective tis- 
sue and the structures passing through it. For our purpose we can 
consider the planes of connective tissue which pass to the sides of 
the pelvis as forming part of the diaphragm and a very important 
part. 

The attachments of the two sides, of course, are exactly the 
same. The muscles and fascia from the two sides pass downward 
and inward toward the median line. Posteriorly, they come together 
on the coccyx, i. e., that part formed by the coccygeus ; anterior to 
this the levator ani muscles come together, interlacing in the median 
fine. On a plane about the level of the posterior surface of the ischii 
the rectum passes through the levator ani ; a little further anteriorly 
there is the vagina passing through, separated from the rectum by 
a reflection of the muscle. The diaphragm is now incomplete, two 
sides extending up to the rami of the pubis. 

Thus, you see, the pelvic diaphragm is a horse-shoe shaped mus- 
cular (also fibrous) septum attached to the sides of the pelvis, pass- 
ing down and inward to meet in the median line, attached to the coc- 
cyx behind, allowing the rectum to go through it, and leaving an oval 
opening anteriorly for passage of the vagina wath the urethra. 

Beneath the pelvic diaphragm lie the diaphragm-pelvico-urogeni- 
tale, the ischio-rectal fossae, the perineum, the vulva, and its glands. 
Since these have only secondary importance in mechanism of labor, 
we will leave their consideration till later. See Sellheim. 

The pelvic floor makes a gutter leading down to the arch of the 
pubis, so that any body free to move, placed on it, will slide down 
under the pubis. 

Posteriorly, the diaphragm is attached to the coccyx, which is 
movable, and the diaphragm possesses a high degree of elasticity and 
dilatability. The degree can be felt from the vagina and the rectum 
and the patient has so much voluntary control of the diaphragm that 
she can compress a body placed in the vagina. Dickinson put some 
moulds of putty in the vaginal outlet and had the women compress 



NOTES ON OBSTETRICS— JUNIOR CLASS. 131 

them. The muscle hypertrophies in some cases of vaginismus and 
may prevent the immissio penis, or the exit of the fetal head. 

During- labor, the diaphragm is forced down, the coccyx forced 
back, the fibres of the diaphragm are separated from each other and 
the muscle is shaped like this : 



Between the vagina and rectum, passing with its apex up to the 
diaphragm, is a pyramidal body, the "perineal body/' Its base is the 
skin between the anus and vulva, anteriorly, the vagina and fossa 
navicularis, posteriorly, the anus and rectum. 

It is made up of perineal muscles, and sphincter cunni anteriorly, 
the sphincter ani, posteriorly; the levator ani enters it at the apex 
as it goes between the vagina and rectum. The rest is fat and con- 
nective tissue. At the sides are the ischio bulbous and cavernosus 
muscles. 

This body has a high obstetric importance, but not so much as the 
pelvic floor diaphragm. It may be considered as part of the second 
diaphragm placed beneath the first, and made up of the fat, the 
vulva, the muscles surrounding the vulva, the skin of the perineum 
and the anus. 

During labor the apex of the perineal body with the levator ani, 
to which it is attached, is pushed backward by the advancing head. 
The base is flattened out, i. e., the side toward the vagina and vulva 
is carried downward and forward. The constrictor cunni is dis- 
placed downward and forward, forming part of the pelvic diaphragm 
now. The perineal body is thus flattened out and lies flat on the 
stretched and dilated pelvic floor diaphragm and vagina. 

The bladder is situated behind the pubis in its empty condition, in 
front of the vagina and uterus, to which it is attached. When full 
it pushes back, and its fundus rises above the symphysis into the ab- 
domen, usually to one side. 

Some of the fibres of the levator ani are attached to its base and 
the pelvic fascia forms ligaments for the bladder and the urethra. 
Owing to the attachment -of the bladder to the lower uterine seg- 
ment during the dilatation of the latter in the first stage, the bladder 
is drawn up out of the pelvis, becoming an abdominal organ. This 
puts the urethra on the stretch, elongates it and gives it a direction 



132 NOTES ON OBSTETRICS— JUNIOR CEASS. 

off to one side (to which the bladder is). Point to be remembered 
in catheterization. 

The vagina becomes dilated so that it lies on the pelvic diaphragm 
all around, really forming an upper layer for it. Thus, when the 
pelvic floor tears, the vagina usually takes part. Sometimes the floor 
tears, the vagina remaining intact. This should be recognized after 
labor. Sometimes the muscle tears from the pelvic wall. The rec- 
tum is pushed back directly against the coccyx and sacrum by the 
advancing head. Owing to the downward and backward displace- 
ment of the anus, the downward and forward displacement of the 
perineal body, and the tension from the two sides, the anus is open 
and its anterior wall becomes visible. 

The two pelvic segments, the sacral and the pubic, are thus sep- 
arated by the advancing head. The pubic segment, uterus, vagina, 
bladder, and urethra are drawn up, the sacral segment, rectum, pel- 
vic floor, and perineum are pushed down. The action may be likened 
to a body passing through folding doors pulling one toward him 
and pushing the other away. The skin is simply stretched over all 
like a tight cap with a split in its anterior portion, through which 
the child comes. Describe the parturient canal; see plates of Braune. 
Hodge's casts. 

THE PASSENGERS. 

We next take up the consideration of the passengers, — the fetus 
and the secundines. The position of the fetus in utero and the points 
which characterize its maturity, have already been given, in the 
]jhysiology of pregnancy. 

The larger and more important part of the fetus is the head, the 
shoulders being so soft and compressible, that they present usually 
little interest in normal labor. Do not underestimate them, however, 
as they may give rise to dystocia and, Avhat is more, may directly 
cause the death of the mother or fetus, or both, when too large, or 
when they come in a bad position. 

The fetal head at term is an irregularly ovoidal body, anteriorly 
narrow, broad behind. 

The four large squamous bones, which make up the vault of the 
cranium, are connected together by sutures. At the junction of 
the sutures there are spaces filled with the membrane, in which the 
bone is formed. These are called fontanelles. 

The sutures are, anteriorly between the two halves of the frontal 
bone, frontal suture ; laterally, between the frontal and parietal bones, 
is the coronal suture ; in the median line, on the vertex, is the sagittal 
suture, the most important, and behind, between the parietal and oc- 
cipital bones, the lambdoidal suture. 

At the sides, between the parietal bone and the temporal, on each 
side, are the lateral sutures. 



NOTES ON OBSTETRICS— JUNIOR CLASS. 133 

At the junction of the frontal, the sagittal and the coronary su- 
tures, is a lozenge-shaped space, the anterior or large fontanelle. Its 
size depends on the degree of ossification of the cranial bones, but it 
offers no index as to the maturity of the child. The shape of the 
fontanelle is important in that by it we can distinguish the position 
which the fetus holds in utero. It is characterized by four sutures 
running to it, and second by the fact that one angle is obtuse, the 
other acute and long: The short obtuse angle points always toward 
the occiput, or posterior pole of the head, the long acute angle points 
to the face. The anterior pole of the fetal head is called the sinciput, 
and is about the highest part of the forehead. The occiput is the 
prominence of the occipital bone. 

Posteriorly, where the sagittal suture meets the lambdoidal, a 
triangular space exists called the posterior or small fontanelle. This, 
during labor, or often at all times, is felt, not as a space, but as a 
meeting of three sutures. It is characterized by the fact that there 
are three sutures, not four. The concavity of the angle 
which they make, points to the occiput. 



It sometimes happens that at some point in the sagittal suture 
there is a quadrangular space, an accessory fontanelle ; this is usually 
about half-way between the two fontanelles, four cornered. It may 
lead to diagnostic mistakes unless it be recognized. 

Laterally, where the lambdoidal suture meets the lateral suture, a 
space may be felt, like a fontanelle, which may also be diagnosed as 
either the anterior or posterior fontanelle. This mistake is avoided 
by the palpation of the ear directly alongside of it. Sometimes the 
spaces of the fontanelles (not the anterior) are filled with an extra 
plate of bonCj from which ossification goes on independently. These 
are called. Wormian bones. The parietal bones on each side have a 
prominence which may be more or less marked. Sometimes this is 
quite pointed. They are called the parietal bosses and they mark 
the point where the head meets with the greatest resistance in pass- 
ing through the pelvis. 

The rest of the head interests us only as regards the measure- 
ments. To study the mechanism of labor it is important to know 
the dimensions of the head. 
Diamteters : 

Bi-parietal, gVz. Jji-temporal, SjA c. m. 

Occipito-frontal, ii. Occipito-mental, 13 c. m. 

Sub-occipito-bregmatic, 9J/ c. m. 

Bis-acromial diameter is 11 c. m. Bi-troch, 10 c. m. 



134 NOTES ON OBSTETRICS— JUNIOR CLASS. 

Circumferences'. 

Occipito-frontal, 34 c. m. 
Sub-occipito-bregmatic, 31 c. m. 

Baby is 50 c. m. long. At the 5th month is 26 c. m. long, and 
gains 5 c. m. a month. It weighs 3,200 grams on an aver- 
age. 

In general, small women have small babies ; large women, large 
babies. Short, fat women are an exception, as they often have large, 
fat babies, but in them the pelvis is usually of normal shape, and of 
good size, so there is no dystocia. Still, fat women are liable to post 
partum hemorrhage, so that labor in them requires watchfulness. 

The shape of the fetal head bears some relation to the mother's 
head ; said that it is a miniature of hers, but this is not always true. 

The shape of the head may vary much, both from the moulding 
during labor (which soon disappears), and from congenital forms of 
growth and of changes due to premature union of the sutures {syno- 
stosis) . 

I. Dolichocephalus. 
11. Scaphocephalus (first named by Ernst v. Bear). 

This is due to a too early synostosis of the parietal bones. There- 
fore, the head is boat-shaped, Bi-parietal, less than Bi-temporal diam- 
eter. 

III. Trigonocephalus — premature synostosis of the frontal 
bones. 

The fetal head bears some relation to the father's, in that a large 
father will have a large child. Thus it happens that a small woman 
sometimes bears a large child. 

The number of the pregnancy has some relation also to the size 
of the child, as before stated, the second pregnancy generally a small 
child, after this, an increase of 5 to 8 ounces, with every baby, till 
the seventh or eighth, when usually a decrease begins. In primi- 
parae, the head is larger proportionately to the shoulders, than in 
multiparae. The latter also have fatter babies. 

The fetus presents itself for labor in a variety of positions. It 
may present any part of its anatomy to the parturient canal. 

Definition. The presentation of the fetus is determined by the 
part which is touched by the examining finger or is bounded by the 
girdle of resistance. 

Definition. The position of the fetus is determined by the rela- 
tion of a given point in the presenting part to certain points in the 
periphery of the pelvic planes. 

Definition. That point of the presenting part which is used for 
determining the position is called the "Point of Direction." It varies 
with the different parts, e. g., in occipital presentation, the occiput ; 
in breech presentation, the sacrum ; in shoulder presentation, the 
scapula ; in face presentation, the chin. 



NOTES ON OBSTETRICS— JUNIOR CEASS. 135 

The classification of the presentations which is generally recog- 
nized is that adopted by the 9th International Medical Congress at 
Washington in 1887. 

I. Cephalic Presentation. 

Including Vertex and varieties. 

Face — Brow and varieties. These depend on the de- 
gree of flexion of the head. 
II. Breech Presentation. 

Including Double or Complete Breech. 
Footling or Knee presentation. 
Single Breech. 
III. Transverse Presentation. 

Including Shoulder — Trunk presentation. 
The presenting part occupies such a position in the pelvis that 
its point of direction looks either to the right or to the left, behind 
or forward. For convenience of description the pelvis is divided 
into four quadrants — an anterior left, an anterior right, a posterior 
left and right. The position is defined according to that quadrant in 
which the point of direction lies. 

All terms as to direction apply to the mother, in the erect position. 
The term upper means the part in the direction of the fundus uteri ; 
lower, the part nearer the vulvar outlet ; anterior means the direction 
to the front ; everything, as was said, in reference to the mother. 

In Cephalic presentations, considering vertex, or as it is usually 
called, occipital presentation, first, we have 
I. Occipito Laeva Anterior — 0. L. A. 
II. Occipito Dextra Posterior — 0. Z>. P. 

III. Occipito Dextra Anterior — O. D. A. 

IV. Mento Laeva Posterior— M. L. P. 

The occiput is the point of direction. There is no reason for 
adding the word iliac (the letter I) to indicate that the head is near 
the ilium. 

When the Face presents, we have : 
I. Mento Dextra Posterior — M. D. P. 
11. Mento Laeva Anterior — M. L. A. 

III. Mento Dextra Anterior — M. D. A. 

IV. Mento Laeva Posterior — M. L. P. 
Point of direction is the chin. 

When the Bron^ presents we have the same divisions substituting 
"fronto" for "mento." We have all degrees of deflexion and it 
is not necessary or wise to enter each in general classification. 
When the Breech presents : 

I. Sacro Laeva Anterior — Sac. L. A. 
II. Sacro Dextra Posterior — Sac. D. P. 

III. Sacro Dextra Anterior — Sac. D. A. 

IV. Sacro Laeva Posterior — ^ac. L. P. 



136 XOTES OX OBSTETRICS— JUNIOR CLASS. 

Point of Direction is the sacrum. 

Footling and Knee presentations are named after tlie Breech. 

When the Shoulder presents: 

I. Scapula Laeva Anterior — Sc. L. A. Back anterior 
11. Scapula Dextra Anterior — Sc. D. A. positions. 

III. Scapula Dextra Posterior — Sc. D. P. Back posterior 

IV.' Scapula Laeva Posterior— 5^c. L. P. positions. 

Point of direction is the scapula. 

To this classification two additions ought to be made, (a), one to 
determine the relation of the head in a vertical plane, that is, its 
distance from the vulvar outlet, and (b) one to designate those posi- 
tions of the head when its long axis is in the transverse diameter of 
the pelvis. For the latter the writer suggests the term transverse, 
and thus we have O. L. transverse when the occiput points to the 
left, and'O. D. transverse when the occiput points to the right. 

For the former condition the writer has used the term degree of 
engagement. IMueller suggests the word "station." A head is ''not en- 
gaged" wh'en its greatest diameter is still above the plane of the inlet. 
If freely movable, we call it floating or caput ballitabile. A head is 
fixed on the inlet or "engaging" when the largest diameter is just 
about to pass the inlet — caput mobile. A head is "engaged" when 
the largest diameter has passed the plane of the inlet — caput ponde- 
rosum. A head is "deeply engaged" when the lowest part of the 
head rests on the pelvic floor. A head is "at. the outlet" when the 
largest diameter is passing the bony outlet. The perineum is bulging 
at this time. A head is "on the perineum" when the largest diameter 
has passed the bony outlet and the head begins to show in the vulva. 

Attitude. This is the relation of the various parts of the anato- 
my of the fetus to each other. The normal attitude of the child is 
one of flexion of all the joints. Attitude may be disturbed by the 
arms leaving the chest, the legs leaving the abdomen and prolapsing 
or the cord prolapsing, the chin extending (making face presenta- 
tion). 

Frequency of the Presentations. 

Carl Braun's Clinic — 48,449 cases about 1865 to 1875. Vertex, 
95 9-10%. Face, 6-10%. Pelvis, 2 7-10%. Transverse, 7-10%. 
Of the vertex presentations 70% were O. L. A and 29% O. D. P. 
1% the other two presentations. 

Causes of the Presentations and Positions. 

1. Gravity. If a fetus is placed in a fluid having a specific grav- 
ity similar to that of liquor amnii, it will float with the head down 
and the right side a little lower than the left (liver). In the latter 
months of pregnancy, the head sinks into the lower uterine segment. 

2. Laiv of Accommodation of Pajot. Where an ovoidal body is 



NOTES ON OBSTETRICS— JUNIOR CLASS. 137 

in an ovoidal container, the long axes tend to become parallel. Es- 
pecially true when the container contracts as does the uterus. This 
is assisted by the steadying action of the abdominal walls. Multi- 
parae and women with lax uteri and abdominal walls are likely to 
have mal-presentations, while primiparae seldom have them : said 
that the proportion is 7 to i. The active movements of the fetus 
tend to force the head down. Influence of hydramnion in producing 
mal-presentations — great mobility conferred, therefore child lies in 
any position when labor begins. Size of the fetus — lack of mobility, 
therefore head presentation, usually with large children. ]\Iaturity 
of fetus, same as size, premature labors often breech. Abnoruialities 
of the fetus, for example, hydrocephalus, anencephalus, predispose to 
breech. Accident. When the patient is brought suddenly to labor 
with the fetus in bad position. 

Shape of the Uterus. In uterus arcuatus, find shoulder and 
breech presentation. Contraction of the pelvis, presenting part can- 
not go in, so glides off. During pregnancy the presentation and the 
position change frequently. In primiparae after lightening the posi- 
tion is usually but not always fixed. In multiparae it may change up 
to the beginning of labor. Changes are mostly breech to vertex and 
transverse to vertex. Head to breech and transverse to breech are 
rare. AMiat are the causes of the various positions of the child ? 

Nervous Mechauisui of Labor. 
Quite complicated and by no means certain as yet. 

Nerve Centers. 

1. A center is believed to exist in the cortex. 

2. A reflex center called the parturition center exists in the 
medulla, but the importance of it is variously estimated. 

3. A center in the lumbar enlargement of the cord. 

4. Independent nervous centers in the uterus. This is proven by 
the fact that labor can occur in cases where all connections with the 
spinal cord are cut off. ist, cases of paraplegia, and experimentally 
after section of the spinal cord. This center is supposed to be the 
great cervical ganglion. 

Nerves. 

1. ]\Iotor fibres are derived from the aortic and hypogastric 
plexuses, sympathetic. 

2. Sensory fi.bres pass along the sacral nerves to the spinal cord. 
Thus generally in cases of paraplegia labor is painless, and the in- 
jection of cocaine into the spinal canal affects these fibres, producing 
anesthesia of the region supplied by the nerves of the cauda. The 
action of the uterus is undisturbed. 



138 NOTES ON OBSTETRICS— JUNIOR CLASS. 

LABOR MECHANISM IN OCCIPITO LAEVA ANTERIOR. 

Movements imparted to the fetus. 

For the study of these movements a multipara offers better advan- 
tages than a primipara because in the latter the head is already 
engaged, while in the former . it does not engage until the labor. 
The head lies over the inlet more or less median, being inclined more 
or less on either shoulder. This latere flexion of the head brings 
the sagittal suture nearer the promontory or the pubis and one pari- 
etal bone lower than the other. When the head lies in the inlet with 
the sagittal suture midway between the pubis and promontory it is 
said to. be synclitic or in synclitism. When the sagittal suture is 
nearer one than the other the head is asynclitic. As the head de- 
scends into the pelvis this asynclitism disappears, the sagittal suture 
becoming median. The motion is called the synclitic movement, or 
'levelling." In pathological cases the asynclitism is marked, a pro- 
nounced anterior or posterior parietal bone presentation being pres- 
ent, or the asynclitism may persist till the head reaches the pelvic 
floor and interferes with internal anterior rotation. 

I. The head enters the pelvis in the right or ist oblique diameter; 
it may be more transverse, but unless the pelvis be contracted, it 
seeks the oblique ; reason of this, the greater length of the diameter, 
the transverse diameter being encroached on by the ilio-psoas on 
each side. The head enters the pelvis with the chin flexed on the 
sternum. The reasons for this are, ist, the normal position of the 
fetus from the early weeks, is one of flexion ; 2nd, in the inlet, 
certainly after the head has reached the chief pelvic plane (i. e., 
about the level of the pyriformis) it meets with resistance. The 
head therefore descends in the pelvis in a flexed condition, undergoes 
little change till it reaches the chief pelvic plane. The flexion 
or £rst movement is increased by the resistance which the head 
meets. The head may be considered as a two-armed lever balanced 
on a point lying in the condyles of the occipital bone. The short end 
of the lever lies toward the occiput, the long end toward the sinci- 
put. 

The force is applied through the spinal column to the condyles. 
The resistance is the same all around and therefore the short end of 
the lever must sink ; this serves to increase the flexion already begun ; 
the sinciput goes up, the occiput goes down. Under certain condi- 
tions this flexion may be so great that the occipito-frontal diameter 
coincides with the long axis of the fetus. A generally contracted 
pelvis does this, and coming to a case in which the flexion is extreme 
you may diagnose a generally contracted pelvis. 

The mechanical gain in flexion is that instead of an occipito- 
frontal diameter of 11 cm. and circumference of 34, we get a suboc- 
cipito-bregmatic diameter of 9 cm. and circumference of 31 cm. 
Time when — place where. 



NOTES ON OBSTETRICS— JUNIOR CLASS. 139 

Flexion occurs at the end of the first stage or at the beginning 
of the second stage in multiparae. In primiparae ahiiost always 
first stage. 

Place where, already mentioned, in the mid-plane. 

II. Coincident with this is the descent of the head. This is 
called the second movement, and occurs in the axis of the inlet. 

Descent is the result of three factors, i. General intra-uterine 
pressure; 2. Extension of the fetal body; 3. Gravity. Descent is 
continued till the head reaches the pelvic floor. During the descent, 
the head strikes the lateral plane of the pelvis, the left anterior in- 
dined plane. This directs the occiput toward the arch of the pubis, 
and brings about the third movement — 

III. Internal Anterior Rotation. In this movement the small fon- 
tanelle comes anterior, the sagittal suture, which was in the right 
oblique, comes to lie antero-posteriorly. There are several factors 
causing the anterior rotation of the occiput, i. The lateral inclined 
planes of the pelvis together with the gutter formed by the pelvic 
floor. 2. The back of the fetus tends to come anteriorly, since, owing 
to the loss of liquor amnii, the uterus tends to flatten out and the 
convex back of the fetus cannot accommodate itself to the side of the 
uterus as well as to the front. The rotation of the trunk is trans- 
mitted to the head and this assists the action of the ist factors. Can 
act only when the head is flexed, because then the neck is curved 
and rigid and the chin rests on the sternum. 3. The fact that the 
rami of the os pubis converge anteriorly formmg ways, similar to the 
ways of a ferry boat pier, directing the occiput to the front. 

The back does not rotate to a point directly anteriorly, but re- 
mains about 30 degrees behind the head. Internal anterior rotation 
is a very important part of the mechanism of labor. Without it, 
under normal circumstances, delivery could not occur. If the pelvis 
is large or the head very small the latter may pass out transversely. 

When the head has rotated and has come to lie on the pelvic floor 
it is prevented from rotating back again by the sling-like levator ani, 
and is directed downward and forward. 

It is believed that the pelvic floor is mainly causative of rotation, 
the other factors playing a lesser role. The ease and rapidity of the 
anterior rotation depends greatly on the flexion of the head; unless 
same is flexed it will be delayed or absent. 

Time When, Place Where — 

This movement occurs when the second stage is nearly ended in 
multiparae; in, the second stage or sometimes in the first in primi- 
parae. Occurs when the head has reached the cavity of the pelvis, 
in a plane a little below mid-plane. Sometimes, however, the head 
goes straight down to the pelvic floor with the sagittal suture, still 
in the oblique diameter, then it suddenly rotates, or rarely the rota- 
tion is completed in the vulva, or not at all. 



140 NOTES ON OBSTETRICS— JUNIOR CLASS. 

Fourth Movement. 

IV. After the head reaches the pelvic floor, rotation being com- 
pleted, descent and extension of the head now occur. After the head 
slips down under the pubic arch, the occiput becomes fixed. 



Now the fetal axis pressure works on a one-armed lever and the 
sinciput descends. When the head reaches the pelvic floor it strikes 
an inclined plane. The force meets the resistance of the plane and 
by resolving the forces we see the head slide down the plane. This 
brings the occiput under the symphysis. Now the Fetal Axis Pres- 
sure acts at a different angle, in a direction more posteriorly, which 
serves to force the sinciput down, i. e., to deflex it. 



■ Another explanation is this : General Intra Uterine Pressure 
acts equally on the head in the parturient canal, and forces it along 
the gutter of the pelvic floor. Owing to the shape of this, head 
must follow the curve. 

The occiput being fixed under the pubis, the forehead, face and 
chin roll over the perineum, the center of rotation being a line drawn 
through the occipital condyles posteriorly. 

Time When, Place Where — 

In primiparae and multiparae at the end of the second stage. At 
the outlet of the hard pelvis and the outlet of the soft pelvis. 

•♦ Fifth Movement. 

V. After the head has escaped, the occiput slowly turns to the 
left side, the face to the right. This i? due to the internal rotation of 
the shoulders, and, second, to the slight twisting which the neck has 
undergone, now being untwisted. 

The shoulders enter the inlet in the left oblique, and rotate ante- 
riorly in the same manner as the head, but the anterior shoulder 
comes anteriorly from the right side of the pelvis. This causes the 
head outside to rotate in the same direction. This movement is 



NOTES ON OBSTETRICS— JUNIOR CLASS. 141 

aided by the untwisting of the neck. It is called External Tiestitu- 
tion. This does not invariably occur. Thus there are five move- 
ments of the head, flexion, descent, internal anterior rotation, exten- 
sion, external restitution. 

Mechanism of the Shoulders. 

The shoulders enter in the oblique diameter opposite that taken 
by the head. The anterior shoulder passes through the same mech- 
anism as the occiput and rolls under the symphysis, the posterior 
shoulder sliding along the pelvic floor. 

The anterior shoulder stems under the symphysis while the pos- 
terior shoulder rolls over the perineum, then the anterior shoulder 
comes out from behind the symphysis. This mechanism is not con- 
stant, sometimes the shoulders do not rotate but come out some- 
what obliquely, or even transversely (rare). Or the posterior 
shoulder may stay behind the perineum till the anterior shoulder is 
d.elivered. 

Seldom any trouble with the shoulders unless they are too large, 
but their exit must be watched and they sometimes tear the perineum 
even if the head passes through safely, or may increase a small tear. 

What One Feels of the Mechanism of Labor. 

At the beginning the head is high up in the pelvis, and you must 
press the perineum well back to reach it. 

In multiparae the head is still movable, "caput hallitahile." If 
the cervix is dilated, through the bag of w^aters, you can recognize 
the head and usually can feel a suture, running nearly in the right 
obhque. Passing to the left anteriorly, following the suture, you 
reach the small fontanelle. This is an important finding. It points 
to the left ilio-pubic tubercle, lies in the left anterior quadrant of the 
inlet. 

The sagittal suture generally runs midway between the promon- 
tory and the symphysis, but it may be found more transversely and 
running close to the promontory — anterior synclitism. This is be- 
cause the axes of the uterus and the child do not correspond with 
that of the pelvis. The head, therefore, lies over the inlet with the 
anterior parietal bone lower than the posterior. The sagittal 
suture is, therefore, displaced upward and toward the promon- 
tory. This is called Naegele's obliquity. In normal cases this is 
sometimes present, and when present is always moderate. In patho- 
logical cases, however (especially flat rachitic pelves), the sagittal 
suture may run quite close to the promontory so that the ear is pre- 
senting over the inlet. Dangerous cases. 

As has been said, the head enters the pelvis in the oblique diam- 
eter. This has been called the obliquity of Solayres. The position 
of flexion of the head on the chest is called the obliquity of Roederer. 



142 NOTES ON OBSTETRICS— JUNIOR CLASS. 

Of these the obHquity of Naegele is the only one of importance. 
When the head is high up, flexion not having occurred, you may 
also reach the large fontanelle. It is a little higher than the small. 
When the head has descended and flexion occurred, the head is 
reached easier, the small fontanelle lies to the left anteriorly, the 
large fontanelle can usually be reached, but is high up to the right 
sacro-iliac joint and hard to get. Sagittal suture in right oblique. 
Naegele's obliquity, if present at first, exists no more. The head is 
now fixed in the inlet, ''caput mobile." Can be pushed up, but with 
difliculty. When the head has descended so that the lowest point 
lies in a line drawn between the two ischiatic spines, the head is 
fixed, or "engaged" "caput ponderosum." 

The head is engaged when the largest plane, the one through the 
bi-parietal diameter, has passed the plane of the inlet. What are the 
signs by which we may determine whether engagement has or has 
not occurred ? The head is engaged when, first, the most dependent 
portion has passed the "interspinous line" ; second, when two-thirds 
of the sacrum are covered ; and, third, when three-fourths of the 
symphysis are covered by the head. Never operate till you know 
whether the head is engaged or not. 

When anterior rotation is complete, the small fontanelle has come 
to the median line in front, and the sagittal suture into the antero- 
posterior diameter of the plane of the outlet. By this time in long 
labors the caput succedaneum has begun to form, which may make 
the landmarks on the scalp hard to find. By even pressure with the 
finger, one can usually obviate the difficulty. The perineum now 
begins to flatten out, then to bulge. This soon becomes greater, and 
now during a pain the lips of the vulva are separated and one can see 
the head. After the pain is over the head recedes, but comes down 
further with the next pain. This is a continuation of the movement 
from the start, there being advance and recession alternating. The 
head is said "to feel its way." The vulva opens more and more, 
thick mucus comes out, the parts being very succulent. Finally the 
head is expelled, etc. 

By abdominal examination the progress of labor is determined 
by the palpatory findings, and auscultation, until the head is well 
down on the floor of the pelvis. The fundus of the uterus lies high 
up, near the ensiform, the progression of the head being accom- 
plished by the extension of the fetus. At first the shoulder may be 
felt directly anteriorly, but as rotation is completed it goes to the 
right side. The heart tones heard at first between Poupart's liga- 
ment and the navel in front, sink toward the pelvis, at the same time 
nearing the median line. In forceps operations, therefore, listen just 
above the symphysis near the hair margin. The rotation of the 
head can likewise be followed by the hand palpating through the 
abdomen. The head is grasped firmly and its position noted. The 



NOTES ON OBSTETRICS— JUNIOR CLASS. 143 

forehead rises in L. O. A. as flexion occurs, and rotates behind with 
the internal anterior rotation of the occiput. The advancement and 
engagement of the head can also be determined from the outside, by 
noting the depth which the hands must be pressed to reach the head. 

The Mechanism of Labor in Right Occipito Posterior. 

Meclmnism the same, but the third movement, internal anterior 
rotation takes more time.' The occiput descends, the chin flexed as 
usual. Very soon the occiput strikes the posterior part of the right 
lateral inclined plane. If the pyriformis is well developed, if the 
spines of the ischium are normally incurved, the plane is well devel- 
oped and the occiput is directed anteriorly. This movement is as- 
sisted by the trunk, turning anteriorly. Should there be a rather 
large pelvis with poorly marked lateral planes, the head will sink to 
the floor of the pelvis with the occiput directed more or less posteri- 
orly. Rotation now^ takes place so that the sagittal suture comes to 
lie in the transverse diameter, later in the left oblique and in the 
antero-posterior, the small fontanelle coming to the pubis, three- 
quarters of half of a circle being traversed by the occiput. Labor is 
now the same as in O. L. A. External restitution is more common 
and more marked. 

Why does not the occiput rotate into the hollow of the sacrum, 
being so near it? It does sometimes, under pathologic conditions, 
especially in large pelves, or with very small babies. In normal 
cases this abnormal rotation is prevented by incurvation of the 
spines of the ischis, the pyriformis and finally by the shape of the 
pelvic floor. In 3 cases out of 100 the posterior rotation occurs. The 
back of the fetus tends to come to the front, and it brings the occiput 
with it. Another factor favoring anterior rotation is the fact that 
the shoulder of the fetus strikes the promontory of the sacrum and 
a rotation of the head backward would be communicated to the shoul- 
der, but is thus prevented. Sutugin says that the back is to the side 
alw^ays, w^hich would favor anterior rotation of the head in this way. 
After anterior rotation has gotten the head into the transverse diam- 
eter the mechanism is the same as that of O. L. A. 

Findings. 

Abdominally, the back is felt posteriorly and to the right. The 
heart tones more in the flank half way to the navel. During labor 
both gradually come anteriorly, sinking at the same time. The 
shoulder is on, the right side of the median line, and turns to the 
front, then to the left side of the center, as labor progresses. The 
forehead at first is plainly- felt above the left ramus of the pubis. It 
rises a little higher, due_to flexion of the head, then it sinks lower, 
advancement, finally it sweeps around the left half of the pelvis, dis- 
appearing at the side. Internally at the beginning of labor, head 



144 NOTES ON OBSTETRICS— JUNIOR CEASS. 

high up, sagittal suture in right obhque, large fontanelle left 
anteriorly, small fontanelle high up and to the right sacro-iliac joint. 
Flexion is less marked in these cases. After descent started, the 
flexion of the head throws the small fontanelle nearer the finger, 
the large fontanelle recedes and sagittal suture becomes more verti- 
cal. Should flexion remain out, the head reaches the perineum, fhe 
small and large fontanelles descend in nearly the same plane, the 
sagittal suture running more or less transversely. After rotation 
is completed, the findings the same as O. L. A. 

Labor is always longer, harder, effacement and dilation of the 
cervix not so complete, and more painful in occiput posterior posi- 
tions. The occiput has to rotate through an arc of almost 140 de- 
grees, three-quarters of half circle, whereas in O. L. A. it has about 
45 degree to traverse, one-quarter of half circle. The spontaneous 
completion of labor depends, therefore, on powerful uterine contrac- 
tions aided strongly by the abdominal muscles. In a long labor both 
are likely to be exhausted and so we often see cases of relative in- 
sufficiency of the powers of labor in O. D. P. In these cases 
labor comes to a standstill, the sagittal suture usually in the trans- 
verse diameter, or part of the anterior rotation completed but the 
small fontanelle not all the way around. 

The points to remember in occiput posterior positions are: ist. 
Descent and flexion are slower than in occipito-anterior positions. 
2nd. If the spine of the ischium is well developed, the anterior late- 
ral inclined plane is well marked, and will direct the occiput anteri- 
orly. 3rd. The shoulder impinging on the promontory of the sacrum 
tends to prevent the posterior rotation of the head. 4th. That ante- 
rior rotation may not occur until the head is well on the pelvic 
floor. 5th. That labor is much longer and slower than in occipito- 
anterior positions, dilation of the cervix is slow. 6th. That occipito- 
posterior position is eutocia usually. 

Changes in the Fetal Head. 

The caput succedaneum vv^as already described. It is always 
found on the more dependent side of the head. This is almost 
always the anterior side of the head. In O. L. A., therefore, the 
right parietal bone, and since the occiput presents, the posterior part 
of the bone shows the caput succedaneum. In O. D. P. positions 
the caput succedaneum is situated on the left parietal bone. We can 
thus diagnose the position which the fetus held in utero after it is 
born. In addition to the edema., and exudation of the caput succe- 
daneum, there are almost always some small hemorrhages in the 
skin. These remain long after exudation is absorbed and show the 
site of the caput succedaneum. 

The head during labor, especially if it passes through a tight 
pelvis, imdergoes a very slight diminntion in size. This is due pos- 



NOTES ON OBSTETRICS— JUNIOR CLASS. 145 

sibly to an escape of the cerebro-spinal fluid from the head into the 
spinal canal. It is certainly not due to compression of the cerebral 
contents, since the contents of the skull answer the same physical 
laws as fluids, i. e., are incompressible. 

The shape of the head is much altered. Since the chin is strongly 
flexed on the chest, it follows that the head is flattened from the 
large fontanelle toward the nape of the neck. The sagittal diameters 
of the head, therefore, may be increased. The suboccipito-breg- 
matic diameter is decreased, joccipito-m.ental and occipito-frontal 
are increased in length. The result of the compression, which the 
head undergoes all around, causes the forehead to be flattened out 
and the occiput to project in the form of a pomt. The bi-parietal 
diameter is also decreased. The head offers thus a longer, narrower 
cylinder to the birth canal. These changes in shape of the head 
are possible by means of the elasticity of the bones, and the loose 
connections they have with each other, at the sutures. 

In cases where the head meets with an ordinary amount of re- 
sistance the bones overlap at the sutures. The occipital bone is 
generally displaced under the two parietal bones, the frontal is 
usually below the level of the parietal bones, and one parietal bone 
is over the other. If the left parietal bone was posterior it is pressed 
in by the promontory of the sacrum, and lies under the right, and 
conversely. Therefore, in O. L. A. the right overlaps the left, in 
O. D. P. the left overlaps the right. This is especially marked in 
contracted pelves where the head is arrested for a long time at the 
inlet with the posterior parietal bone resting on the promontory. 

Along the sutures it is not uncommon to find numerous small 
hemorrhages. Some may be the size of a thumb nail. Occur in nor- 
mal and pathological cases (beautiful specimen in the museum). 
There is another change in the shape of the head, due partly to the 
pressure of the promontory, but more often to the pressure of the 
pelvic floor against the posterior parietal bone. It is an asymmetry 
of the head ivhen zneimd from behind. 

In contracted pelves where the head is forced powerfully against 
the promontory of the sacrum, the posterior parietal bone is forcibly 
pressed in and the asymmetry is marked. In other cases where the 
flattening of the parietal bone is due to the pelvic floor, it is not so 
marked. In O. L. A. it is the left parietal bone which is flattened, 
the right, which is convex. In O. D. P. the reverse. 

Finally we observe an asymmetry of the head not due to the 
mechanism of labor, but to a congenital scoliosis of the spinal col- 
umn. All forms of growth have a slightly spiral direction. True 
also of the fetus. The right parietal bone seems to be pushed in a 
horizontal plane, anteriorly. The left parietal bone is therefore more 
convex, the right appears flat. The cranium is, as it were, twisted 
in a horizontal plane from left to right. This obliquity persists and 



146 NOTES ON OBSTETRICS— JUNIOR CLASS. 

can be found in the adult. Called the asymmetry of Stadtfeld, who 
first described it. During labor in O. L. A. the twist is counteracted 
by the flattening induced by the mechanism or even twisted in the 
opposite direction from left to right. The alteration in shape that 
is induced by labor lasts only 3 to 6 days when it is gone and the 
real asymmetry now may be seen. In cases of O. D. P. the two 
factors combine to produce a marked flattening of the head. This 
becomes less marked later. Breech cases in primiparae sometimes 
present marked deformity of the head. 

Mechanism of the Separation of the Placenta. 

After the expulsion of the child the uterus rests. This period 
lasts from 5 to 30 minutes, then the activity of the uterus begins 
again. During this time the muscle is in a state of retraction, the 
fibres and lamellae are superimposed on each other, rearranged. 
There is no hemorrhage from the mouths of the vessels of the pla- 
cental site because the superimposition of the lamellae mechanically 
closes off the blood vessels and, second, thrombosis occurs in their 
open ends. Of these the second has a relatively unimportant part, 
and more in pathologic cases. 

By this retraction of the muscular fibres, the placenta is mechan- 
ically separated from the uterine wall, since the area of its insertion 
is diminished. This action, of course, is aided by the uterine con- 
tractions. 

2nd Factor. A small hemorrhage forms behind the placenta. 
The placenta is more firmly adherent at the edges than in the 
center, at the rim of the closing plate of Winkler. The hemor- 
rhage, therefore, will lift the placenta up in the center. The next 
pain will force the blood clot between the placenta and the uterine 
wall separating it in the smoothest and most perfect manner. This 
blood clot is the retro-placental hematoma. Sometimes when brisk 
manipulation is made on the uterus, the edge of the placenta will 
loosen from the uterine wall and the blood make its escape externally. 
Under these circumstances we will have an atypical mechanism of 
the third stage. 

jrc? Factor. Is the sudden diminution of intrauterine tension. 

During labor the placenta was forced in contact with the uterine 
wall by the increase in the intrauterine pressure. After this is gone 
there is nothing to prevent the placenta falling into the cavity of the 
uterus. 

4th Factor. In some cases where the cord is less than 35 cm. 
long it must be drawn on to a more or less extent. Separation oc- 
curs in the ampullary layer of the decidua, i. e., at the expense of 
the mother. After the placenta is loosened from the wall of the 
uterus it drops down against the cervix, drawing the membranes 
after it. 



NOTES ON OBSTETRICS— JUNIOR CLASS. 147 

Expulsion of the Placenta. 

This is brought about by the uterine contractions, they force the 
loosened placenta against the internal os, and finally through it into 
the dilated cervix and upper part of the vagina. During this process 
it proceeds in one of two ways. 

1. It turns partly inside out like an umbrella. The fetal surface 
comes out of the uterus first, the cord leading the way, the mem- 
branes containing the retro-placental hematoma following. This is 
called Schultze's method. 

2. The lower edge of the placenta proceeds first, the whole 
organ sliding down the side of the uterus into the vagina. In these 
cases the retro-placental blood clot is small, and the edge of the 
placenta may have been torn off the uterus early, allowing the blood 
to escape. This is called Duncan's Method. The first is the most 
common according to some authors, the latter according to others. 
The placenta often comes out in a manner combining both. In the 
author's experience a pure Duncan's methoil is rarely observed. The 
uterine contractions are aided by gravity, this is of greater value 
when the patient is standing or crouching, and is used mostly by 
savage tribes. 

Finally the abdominal muscles play an important part in the 
expulsion of the after-birth. The uterus alone is not able to expel 
the placenta out of the vagina. The patient bears down and forces 
the placenta out of the vagina and lower uterine segment or the 
physician presses it out. 

The Separation of the Membranes. 

These are drawn mechanically after the placenta from off the 
wall of the uterus. The uterus being in a state of firm contraction, 
can assist this peeling off considerably. They are also occasionally 
separated in part by the retro-placental hematoma and sometimes the 
separation caused by the blood clot may be quite extensive, but this 
borders on the pathologic. After the placenta is outside the vulva, 
the membranes follow slowly to gentle traction. If they are slightly 
adherent, the uterus follows the traction and the anterior lip of the 
cervix may be seen in the vulva. The hemorrhage comes from the 
maternal sinuses. In normal deliveries no blood comes from the 
placenta itself. This may be demonstrated on the placenta by inject- 
ing the vein with milk, no milk appears on the surface of the pla- 
centa. The decidua reflexa is generally attached to the outside of 
the chorion and parts of the decidua vera are torn of¥ the uterine 
wall. Sometimes the decidua vera may remain in the uterus com- 
pletely. It may then be seen as a yellowish gray layer covering the 
mucosa. (Again in physiology of the Puerperium.) 

In cases where the amnion covers the head as a caul, separation 



148 NOTES ON OBSTETRICS— JUNIOR CLASS. 

between the amnion and chorion occurs and the amnion is found 
folded around the cord, attached to the placenta simply at its base. 
The chorion is now stripped off the uterine walls by the placenta and 
is extruded with the decidua. In pathologic cases or where too 
brisk massage is used the chorion may rupture at the edge of the 
placenta and miay tear to a more or less extent, remaining in part or 
toto in the uterus. In these cases the two deciduae remain also, 
and all three have to be expelled in the puerperium. 

After the placenta is extruded, the uterus contracts down to a 
hard pear-shaped body in the inlet of the pelvis. The fundus reaches 
two fingers below the navel. The uterus at first is pear-shaped, and in 
the top, either before or behind, can be felt a flat dimple. This is the 
spot where the placenta was formerly situated and may be used to de- 
termine the location of the placenta. Schroeder found this in almost 
all of his cases. After a few after-pains the uterus loses its sharp 
contour, becomes more globular and rises to the navel, due perhaps 
to a clot, and rearrangement of the muscle fibres. Unless displaced 
by the full bladder, the litems lies directly against the abdominal 
wall, where it may be felt as an alternately contracting and relaxing 
ball. In this stage there is a little bloody flow from the uterus, but 
not over 2 oz. in two hours. The walls of the uterus are very thick, 
6 to 8 times thicker than when the ovum was in it, the anterior and 
posterior walls are applied to each other, imless there is a clot in the 
uterus. At the placental site the wall of the uterus is much thinner 
than elsewhere in the fundus, and very rough, also slightly raised 
above the level of the rest of the uterine mucosa. In the lower uter- 
int segment' the wall is very thin and the rearrangement here is 
slow^er, and it therefore acquires its original thickness later. In some 
cases where the lower uterine segment has been thinned too much 
in a pathologic labor, it may be so thin and soft that it is not palpa- 
ble, but the fingers touch the internal os first. The fundus is folded 
down on the lower uterine segment and vaginal portion of the cer- 
vix. It is not rare to find a clot in the lower uterine segment pro- 
jecting into the vagina. The puerperium begins after the expulsion 
of the after-birth. (See Puerperium later.) 

THE CONDUCT OF LABOR. 

It is of great advantage to know your patient beforehand and 
have made all arrangements with her, have examined her carefully, 
especially the pelvis, have seen and instructed the nurse. You must 
know exactly what you want, must have decided opinions on every 
point and enforce them. There still remains a certain amount of 
superstition about obstetrics and the management of the women 
and babe which you may have to contend with. Nurses also have 
various habits that are grounded in a more or less valuable experi- 
ence. Often vou will be asked, ''How do yon treat the breasts?" 



XOTES ON OBSTETRICS— JUNIOR CLASS. 149 

"Do you use the binder?" '"The belly band?" etc. It is well to have 
all these points settled before the labor, and since, as young physi- 
cians, you will get primiparae principally (the multiparae having 
a leaning toward the doctor who confined them before), you meet 
with little resistance. 

Try to be in town when the case occurs and be sure to notify 
your patient if you are called away, and let her know for whom she 
should send in such emergencies. In case you are called w4ien the 
doctor of the patient is temporarily absent, hand over the case to him 
when he appears. Do nothing to hurry the labor, that it may be 
completed before he comes. Go to a case of labor as soon as you 
are called. Almost always you are called hours too soon, but arrived 
on the scene you may correct a mal-presentation, or prevent some 
puerperal accident ; further, the patient is often nervous and w^ants 
to know if everything is right. You may also leave instructions 
about the preparation of things if the patient happens not to have a 
trained nurse, especially bozi'-els and bladder. Arrived at the case, 
you determine five things : 

I. Is the patient pregnant? II. Is she in labor? III. At term? 
I\'. Parity. \\ Presentation and position, or Diagnosis of the case. 

The signs of pregnancy are easy to determine but errors have been 
made. The diagnosis of labor is more difficult. The two signs : 

1. The regularly recurring painful uterine contractions. 

2. The efitacement and dilatation of the cervix. 

The pains that the multiparae have in the last weeks of preg- 
nancy may be confused with the pains of labor. Most of these 
pains are due to colicky movements of the bowels, but some are due 
to painful uterine contractions and mav be distinguished, ist, by 
their regularity ; 2nd, the uterus does not take the shape we have 
already mentioned ; 3rd, they occur especially at night and disappear 
in the morning-; 4th, they are abdominal and not in the back, as is 
usual in ordinary labor pains; 5th (important), there is no ''show'." 
Treatment, full warm bath and warm enema, or castor oil. 

^rd Question. Is she at term? Except in pathological cases the 
size of the abdomen generally gives sufficient information together 
with the statement of the patient, as the date of last menses. 

4th Question. How" many children? May be denied. A careful 
examination with this point in view may be necessary in legal cases. 

^th. The diagnosis of the case. This is most important. 

Do not enter the room abruptly. Let the patient know you have 
come. Be alert to any sound from the lying-in chamber : you may 
be able to tell "from it whether the patient is in the first or second 
stage, and whether you should hurry or not. Unless necessary do 
not go about the examination immediately, but watch the character 
of the pains and their frequency. Place the hand on the abdomen, 
can feel the uterus even through the clothes. 



150 NOTES ON OBSTETRICS-JUNIOR CLASS. 

Method of Washing Hands for Obstetrical Cases. 

General Rules : 

(i) Keep the hands aseptic by avoiding direct contact with 
infective matter. 

(2) After all dissections, dressing pus cases or erysipelas 

cases, or touching the lochia of puerperal cases, ster- 
iHze the hands. 

(3) After attending diphtheria or scarlet fever cases, etc., 

change of clothing, bath, shampoo head and beard. 
Rules for Sterilising Hands. 
(i) Coat off, sleeves above the elbow for all cases. 

(2) Wash street dirt off with water and much soap. 

(3) Scrub in running water or frequent changes for four or 

five minutes. Rinse and dry. 

(4) Now pare and clean the finger nails carefully. 

( 5 ) Wash for a minute in hot water ; dry the hands and make 

the external examination. After this : 

(6) Get two (2) solutions ready, near the bed: I. i :iocxd 

HgCP. 11. I iiooo HgCP or 1% Lysol. 

(7) Now scrub for five (5) minutes in hot running water, 

paying attention to the creases and under the finger 
nails. 

(8) Wash the vulva with solution No. i, leaving a bit of 

soaked cotton in the vulva. 

(9) Now scrub in the solution No. 2 for a full minute and 

carry the two first fingers still wet with the solution 
directly into the vulva, being sure that they touch 
nothing on the way. 
After having to do with septic cases double the time of each pro- 
cedure, and wash the hands with 95% alcohol just before point nine 
and use sterilized rubber gloves. 

Use sterilized rubber gloves for all cases of labor. Carry two or 
three pairs in the obstetric satchel. 

Few Words about the preparation of the Patient. 

She should take a general warm, soap and water, shower bath, 
paying particular attention to the genitals. The hair should be 
closely clipped, but no need to shave the vulva, save for operations 
and in hospitals. Then the patient should have enema of soap suds ; 
after this has acted, local wash and then with HgCl-, 1/2000, using 
this freely about the hips. She should have a long night dress and 
skirt, over all a woolen wrapper. This is for first stage. In the 
second stage she is in bed and wears a short night dress of the 
smoking jacket pattern. During the labor the nurse applies a steril- 
ized pad to the vulva, supporting it by pinning it to the under gar- 



NOTES ON OBSTETRICS— JUNIOR CLASS. 151 

meiit. This is to catch the mucus and blood which may be dis- 
charged. The necessity for examination is generally understood, 
and the nurse prepares the patient for the same. Patient lies at the 
side of the bed covered with a thin blanket or counterpane. The 
physician prepares his hands as has been described (soap and water, 
brush, nails cleaned, rinse in hot water, dry on clean towel), and 
makes the external examination. 

Cover draw^n down to the pubic hair ; do not uncover this. The 
chemise is drawn up to the ribs. It is better to expose the skin, 
done in a gentlemanly manner it gives no offense. Size of the uter- 
ine tumor noted, fundus, see if a furrow, then the four points of diag- 
nosis of position — ovoid? over inlet? in fundus? where is the back? 
There are a few other points in the diagnosis of presentation and 
position especially emphasized by Leopold, although the methods 
have been known for years. 

1. To distinguish the occiput from the sinciput. Two w^ays. 

A. Two hands. Press down toward the Hnea innominata and 

get the head between them, where the occiput lies the 
hand will sink deeper. 2nd. It will feel a relatively 
flatly rounded body. 3rd. This is relatively nearer the 
median line. Where the forehead lies, the hand will not 
sink as deeply. 2nd. Will feel an angular body high up. 
3rd. It will be further from the median line. 

B. One hand, fingers and thumb separated to the utmost is 

placed palm down just over the pubis and grasps the 
head between them. The same signs will be noted. 
When the head is low^ in the pelvis, latter method not 
serviceable ; have recourse to the first, but this is some- 
w^hat painful, especially toward the end of labor. 

2. To palpate the shoulder. Sink the hand just above the head 
and you wall generally feel the groove which the head makes with 
the neck, now^ pulling upward wath the hand it comes to rest on the 
shoulder. 

3. To palpate the breech, similar procedure, sometimes possible 
to outline the breech, feel the genital crease, and inguinal fold, the 
feet and even the toes in favorable cases. The breech may give im- 
portant information as to the location of the back, e. g., if you feel 
the breech with the heels in front of it, you may say the back is 
directed behind, thus : If the breech is toward the front and the 
heels behind, the back lies in front. Favorable in some cases where 
you cannot feel the back. The position of the head corresponds 
closely with that of the breech. (De Lee's Sign.) 

4. The placenta under exceptional circumstances may be felt. 
This is when it is in the lower uterine segment. A boggy sensation 
here and loss of the sharpness of the parts underneath. Especially 
if there is some hemorrhage in the first stage, one thinks of low 



152 NOTES ON OBSTETRICS— JUNIOR CEASS. 

insertion. Further, if the presenting part be still high up, all three 
make a low insertion probable. Occasionally a circular groove may 
be seen through the thin abdominal wall. No auscultatory signs 
can be relied upon. The heart tones are sometimes covered by the 
placenta. 

5. Feel the round ligaments on either side, more easily on the 
left, note their tension and if they are tender to the touch, also note 
their direction. If the round ligaments run on the anterior surface 
of the uterus the placenta lies on the posterior wall, whereas if they 
run more to the side or even posteriorly the placenta is situated 
anteriorly. Leopold, Bayer, etc. 

6. Note 3.n\ tumors in the uterine wall, especially fibroids. The 
cord has been felt coursing over the back of the fetus. Locate fetal 
movements such as those of the extremities or hiccough, or respira- 
tory movements. 

7. Note the character, severity and length of the uterine contrac- 
tions, this being necessary in determining the progress of labor. 

8. Determine the engagement of the presenting part. This is 
done by means of the tv/o maneuvers used in determining the loca- 
tion of the occiput. The head grasped between the hands or between 
the thumb and fingers is moved from side to side to determine its 
movability. Can also feel how far the head has sunk into the pelvis. 
This is most important part of the examination and should never be 
neglected, i. e., 'Ts the part engaged?" 

9. Auscultation. Make your diagnosis of presentation and posi- 
tion first, and then confirm it by means of the heart tones. In the 
beginning of labor they are high up and to the left half way to Pou- 
part's ligament. Later they come lower and anteriorly, while when 
the head bulges the perineum they are just above the symphysis. 
Thus you may use them to determine the course of the labor. Should 
be 120 to 140. Any permanent increase above 160 and decrease be- 
low 100 or to 80 means danger to the fetus. Notice especially any 
irregularity. A careful observer can notice a weakening of the first 
sound, which is an early sign of fetal danger (i. e., asphyxia). May 
not be heard even when present, e. g., covered by placenta, hydram- 
nion. In 14% of cases can hear the funic souffle. Remember, its 
position over the neck generally means that the cord is around the 
neck. In cases where the cord runs over the back one may compress 
it between the stethoscope and the back, producing a murmur. These 
cases very rare. 

10. Measure the pelvis unless already done. 
The main points of the first examination are : 

1. Accurate diagnosis of presentation and position (ovoid? 

over inlet? in fundus? where is back?). 

2. Engagement. 

3. Determination of life of the fetus. 



XOTES OX OBSTETRICS— JUNIOR CLASS. 153 

4. Character of the uterine contraction. 

5. Pelvic measurements. 

The vahie of the external examination is that we can get the 
information quicker, earlier, less painfully, and with no detriment 
to the patient. A large number of labors can be conducted success- 
fully without any internal examinations and as your experience 
grows you wall be able to do this. Still, expediency prevents it for 
exclusive practice. If you have the time, if the presentation and 
position are good, if the heart tones are normal, you need not make 
an internal examination. Almost always, however, this is made 
because we need all the information we can get, we w-ant to complete 
the pelvic measurements and see if we may leave the case to attend 
to something else. 

The nurse is told to prepare the patient for internal examination 
or you do it yourself. The hands are therefore scrubbed again and 
disinfected according to the formula, and the tw^o first fingers passed 
into the vagina. Pass them all the w-ay in at the start, as they are 
clean, later they become soiled bv contact wdth the skin, hair, etc. 
Describe method of making internal examination. Note first the cer- 
vix — whether it is effaced, whether the os externum is patulous, 
whether you can reach the internal os, if the canal is eft'aced and 
commenced to dilate, how far the dilation has progressed. A good 
method of description is that of the fingers — say that the os admits 
I, 2, 3, or 4 fingers. Another method often used is to say the os is 
the size of a ten-cent piece or quarter or half dollar, and palm of 
the hand. 

A marked dift'erence exists between the primiparae and multi- 
parae with reference to the effacement of the cervix and dilatation of 
the external os. In multiparae the upper part of the cervix is dilated 
and the external os gives way quickly. In primiparae, however, the 
cervix is slowly effaced and dilated from above downward and the 
external os must be dilated by the pains aided by the bag of w^aters. 
In the beginning of labor in primiparae the finger passes along the 
cervical canal for the length of one phalanx and may not pass 
through the internal os. As labor goes on the cervix shortens, the 
internal os dilates. The cervix shortens till only the external os 
remains, it has a thick edge, and is thus described. 

The bag of waters may be felt through the cervix. The cervix is 
taken up more into the uterus, it is effaced, the edge of the cervix 
becomes thin and gradually the os dilates. When the external os is 
flush with the vagina we say that dilatation is complete. In a multi- 
para the process is quicker, as soon as the cervix is eft'aced the exter- 
nal OS, being already partially dilated, expands rapidly. Even at the 
beginning of labor, one or two fingers may be passed through the 
internal os, especially if there have been forceps or other operative 
deliveries, causing laceration of the cervix. In certain cases you come 



154 NOTES ON OBSTETRICS— JUNIOR CLASS. 

to a labor and find that even though the pains have been very slight, 
effacement of the cervix is complete and dilatation of the os com- 
menced, or at an operation undertaken to terminate pregnancy, you 
find things as described. This is called Insensible Labor by the 
P>ench. It happens in cases of eclampsia frequently, and in hydram- 
nion, and is usually heartily welcome. Find it occasionally in latter 
weeks of pregnancy. 

II. The second point to determine is whether the bag of waters 
has ruptured or not ; usually easy but may be hard. Feel a tense, 
smooth membrane over the head, a little pressure and you can touch 
the head through it. This is during a pain (careful not to rupture 
the bag of waters), when relaxed the membrane feels smooth, while 
if already ruptured you feel the head with the hair on it, and the 
bones are felt more distinctly. It takes some practice. If in doubt 
examine during a pain, if still doubtful pass the finger inside the 
cervix, pushing up the head; liquor amnii will now flow into the 
hand (Charpentier). Remember that there may apparently be two 
bags of water, which may be due to (i) twins, (2). rupture of the 
membrane high up, (3) the separation of the amnion and chorion 
and the accumulation of fluid between the two. This fluid comes 
from relics of allantois. 

III. The third point to determine is the presence of the head in 
the pelvis. A hard, evenly round body is the head, but mistakes 
have occurred, e. g., breech. If the os be dilated you may feel the 
sutures through the membranes. If not, it is very hard to feel the 
sutures. May be impossible. 

In the middle of the pelvis, high up, you feel the sagittal suture. 
May be nearer the promontory of the sacrum. ''Naegele's obliqui- 
ty." Following it along you feel the small fontanelle to one side, 
the large on the other. Differentiate them by the number of sutures 
running to each. Three sutures go to the small, four to the large 
fontanelle. The obtuse angle of the large fontanelle points to the 
occiput. The sagittal suture lies in a relatively flat plane of the 
head. The lambdoid and coronal lie in strongly curved planes, this 
serving to distinguish them. The lateral fontanelles are distin- 
guished from the others by having the ear nearby. These points 
enable the position of the head to be accurately determined. 

IV. Now determine how far the head has advanced in the pelvis. 

1. When still movable at the inlet, capnt ballitabile. 

2. When fixed in the inlet, caput mobile. 

3. When past the inlet, ''engaged," caput ponderosum. 

The head is engaged when the greatest diameter has passed the 
inlet. In occipital presentation this is the bi-parietal plane, and this 
is shown clinically, ist, by the lowest part of the head having reached 
the bi-ischiatic line, or passed it ; 2nd, by the covering of the sacrum, 
two-thirds ; 3rd, by the covering of the symphysis, three-fourths. 



NOTES ON OBSTETRICS— JUNIOR CLASS. 155 

The two latter criteria are not as good as the first. Always be 
sure that the head is or is not engaged before operating. The head is 
deep in the pelvis when the lowest part is on a level with the tuberos- 
ities of the ischia. The head is at the outlet when the bi-parietal pro- 
tuberances are passing the tuberosities. It is hard to pass the fingers 
between the head and the bone. The head is on the perineum when 
the parietal bosses have passed the tuberosities and the head comes 
to He in the distended vagina and vulva. The forehead is just pass- 
ing the end of the sacrum. 

In the progress of labor the head comes down to the pelvic floor 
and is met by the finger immediately after passing the vulva. 

V. Examine the pelvis. Run fingers over the walls of the pelvis, 
determine the presence of tumors, the general size of the cavity, the 
ischiatic spines, how they project into the pelvis, palpate the sacrum, 
note its concavity or convexity, and then posterior surface of the 
symphysis, perhaps there is an exostosis here. Now take the Gon- 
jugata Diagonalis. Sink the elbow well and press the perineum well 
in with the two fingers outside, the two fingers inside are carried up 
till they feel the promontory. Here, they are held and the base of 
the index is pressed up against the ligamentum arcuatum. The in- 
dex of the other hand, palmar surface to pubis, now marks the point 
of the ligamentum arcuatum on the finger. In taking out the finger 
note the condition of the perineum and the pelvic floor, whether torn, 
rigid, relaxed, etc. 

During the examination note also the roominess of the vagina, 
the presence of fetal parts in the cervix, the cord or any abnormal- 
ity which we will learn of in the course of the lectures. To sum up, 
we determine by the internal examination, in exact order; 

1. The degree of effacement and dilatation of the cervix. 

2. The rupture of the bag of waters. 

3. The position of the head in the pelvis ; confirm the external 

examination. 

4. The advancement of the head in the pelvis. 

5. Examination of the pelvis, bony and soft. 

6. Abnormalities. 

In every examination determine these points and in the order 
named. Go very slowly, so that the patient be not hurt, and gently ; 
can almost always get the required information. Do not examine 
during a pain in order to preserve the bag of waters, but it is justi- 
fiable to pass the finger gently around the cervix during a pain so as 
to feel the bag of waters, its size, and how much the cervix is di- 
lated, also to determine the tenseness of the membrane and, there- 
fore, the strength of the pain. Otherwise, let the fingers rest at 
the side of the pelvis till the pain has passed away. 

After the examination you will be asked two questions. One is 
certain, ''is everything right?" Tell the woman that everything is 



156 NOTES ON OBSTETRICS— JUNIOR CLASS. 

right, that the baby lies in good position. If there is some anomaly 
do not tell her, unless there is some operation to be done immediately 
and you must use great tact not to frighten her. It is well to tell the 
husband and then, after a second examination, or after watching 
the case may inform the mother that something must be done. The 
second question is, "How long will it last?" Be very careful how 
you answer this. The clock will almost always contradict you, and 
then the patient will lose faith in you. 

During the first stage the treatment is one of Watchful Ex- 
pectancy. Duty of the physician is to observe, not to aid, nature, till 
she has proven herself unable to complete the labor. When nature 
fails, art is to step in. Nothing so reprehensible as meddlesome mid- 
wifery. Let the woman walk around, sitting down occasionally. She 
should not go to bed unless tired or as the end of the first stage nears. 
Pay attention to the bladder every four hours. Diet generally re- 
fused, but she should be pressed to take a little light soup, coffee 
with milk, custard, lemonade, milk shake, cold milk or water. 

The nurse changes the napkin occasionally. Do not let the woman 
bear dozvm in this stage ; it does no good, does very little, if anything, 
to hasten labor, and it tires the woman so that when the second stage 
comes, no strength left. In an occipito-posterior position let patient 
lie on the side for an hour or two, then continue to walk around. 
She should lie on that side to which the occiput points. Patient 
may suffer with nausea, can do nothing for it. Said that "sick la- 
bors are easy.'' Idea that nausea produces relaxation of the cervix, 
therefore easier dilatation. Former practice to administer emetics 
for this purpose has its source here. The first stage lasts about 12 
to 16 hours in a primiparae. It is not necessary to stay in the 
house. 

If the cervix is not effaced or the os just beginning to dilate, 
leave, make a few calls, return. Do not touch anything dirty on 
the way. Return in two hours. An external examination may now 
give you information as to whether you need stay or not. Do not 
make more than two examinations in a normal labor case. If the 
cervix has reached the size of three fingers, not best to leave; cer- 
tainly not if patient is a multipara. In neither case go to too great a 
distance, and leave a list of the places you are going to, with the 
nurse or husband. With a multipara, especially after the cervix 
is dilating, better to be around. The character of the pains is a useful 
criterion, also the character of the previous labors. 

Put the woman to bed when you judge the first stage is about 
ended, to wait the rupture of the bag of waters. After this is broken 
make an examination to see if the cord or one of the members has 
prolapsed. Determine the other points of the internal examination 
at the same time. Sometimes happens, almost always in multiparae, 
that when the bag of waters ruptures, you have to hasten if you 



\OTES 0\ OBSTETRICS— JUNIOR CLASS. 157 

wish to get your hands clean in time. The woman ma\- now be al- 
lowed to bear down, may be encouraged to brace the feet, close 
the glottis and press hard. Use a sheet tied to the foot of the bed, 
to pull on, or use a skipping rope, or let her pull on her husband. 
You may take his place occasionally to see how much she really 
pulls. The patient does not cry so much now, because she feels 
that there is progress in labor. If, however, it be a long, lingering 
labor do not let the patient over-do her strength. She must con- 
serve it as much as possible, as she will need it for the second 
stage. See that the bladder is emptied and avoid a frequent cause 
of dystocia. A tun:or is formed by the bladder over the pubis, soft, 
fluctuating and separated from the uterus by a groove. Important 
finding. The bowel must also be emptied bv enemata, if necessary. 



Anesthesia in Labor 



In November, 1847, Sir J. Y. Simpson first employed chloroform 
to alleviate the pain of labor. Ether had been employed by him 
since January of the same year. Since then the use of ChCl3 has 
become generalized. It met with great opposition at first. But after 
the Queen of England, in 1853 and 1857, had been chloroformed at 
each of her labors, the ChCl3 of the Queen, found a permanent place 
in England. In America and on the continent, still, the question 
is not fully decided. There are those who deny that it is possible 
to produce insensibility to pain without the loss of consciousness, 
and say that anesthesia to the extent of doing so is dangerous. Others 
claim that almost complete absence of pain may be produced, and 
still the patient be awake and alive to the surroundings. A\'e notice 
here two kinds of anesthesia spoken of : 

1. That pushed to a degree to dull the pain, but which allows 
consciousness to be retained. Obstetric degree. 

2. That where anesthesia and absence of reflex action are pro- 
duced. Surgieal degree. 

These two conditions must be kept well apart. In normal labor 
the majority of women do without anesthetics. Great variety in the 
ability to bear pain. Higher bred the woman, less amount of pain 
she can bear. Some women even suffering much will refuse anes- 
thetics. Others, having before had them or heard of them, will cry 
for their use, perhaps at the beginning of labor. Of those known, 
chloroform and ether are used. Each has its adherents. In gen- 
eral surgery, chloroform is said to be more dangerous than ether. 
Point not certainly proven, since numerous deaths after the narcosis 
has passed away may be referred to the ether. In obstetric practice, 
cholorform is most used. It is pleasanter to take, easier to carry, 
more prompt in action, less required, and there is seldom any vomit- 
ing after it. It is not any more dangerous than ether. Very few 
deaths have occurred under its use. but this means obstetric anes- , 



158 NOTES ON OBSTETRICS— JUNIOR CLASS. 

thesia. We have proof that when the anesthesia is pushed to the 
surgical degree that the obstetric patient enjoys some sHght im- 
munity from the dangers of ChCl3. 

The number of anesthesias is enormous, but the deaths exceeding- 
ly few. This comparative immunity should not invite carelessness 
in the use of the agents. Objections to ChCl3 are: ist. Said to 
weaken uterine contraction and retraction and, therefore, retard la- 
bor and cause relaxation of the uterus in the third stage, and hemor- 
rhage. 2nd. The danger of death. 3rd. That it affects the fetus. 
A silly argument is that the woman will not love her offspring as 
much. Ether has the same objections as ChCl3, but it is said it does 
not weaken the pains as much. Objections to anesthetics in general 
are those of ChCl3. There is no doubt that ChCl3 weakens the 
uterine contractions to a certain degree. Early in labor this is of 
great importance. Later, when the pains are good, strong and fre- 
quent, the effect is small. Sometimes ChCl3 may regulate the pains, 
by relieving the patient of the pain, which makes her less willing 
to bear down, the expulsive efforts are increased. Further, if the 
cervix be irritable and resisting, the anesthetic may, by calming 
the pains and relieving the spasm, actually facilitate labor. It is still 
too early to pass judgment on the new form of regional anesthesia 
invented by Corning, and elaborated by Bier and Tuffier, — the cocain- 
ization of the spinal cord. The injection of i/6th grain of cocaine 
into the spinal canal destroys sensibilit}' below the diaphragm. Va- 
rious European clinicians have employed the procedure in labor and 
in this country, particularly Marx, of New York. 

It is wisest to wait till further experiences in general surgery 
indicates the propriety of adopting the practice for obstetrics. My 
personal experience with ChCl3 is so satisfactory that I feel some 
inertia when it comes to taking the trouble to prove the innocuous- 
ness of another. 

Chloral and morphia are often used during labor to meet special 
indications. 

Indications for administering ChCl3 to the obstetric degree: 

1. Great Pain at any stage, especially at end of first and in the 
second stage. 

2. Great Excitability of the patient at the end of the first or in 
the second stage. 

3. Tumultuous pains, at the same time there being some rigidity 
of the cervix, at any period of labor. Think of rupture of the uterus. 

4. To protect perineum^ to prevent too forcible bearing down. 

Conditions. 

1. Labor must be sufficiently advanced. Very near the end of 
the first stage, at least. 

2. Pains must be strong. 



NOTES ON OBSTETRICS— JUNIOR CEASS. 159 

Examination of the patient must have been made. In pathologic 
presentation, must have special indications for ChCl3, as a rule, not 
to be used. 

Selection of Anesthetic. 

If yoii are going to administer it yourself, or have a Dr. do it, 
use ChCl3. If the woman herself, as is sometimes the case, or the 
husband, use ether always. The safety of ChCl3 depends on the 
one who administers it. In cases of labor I use chloroform exclu- 
sively. 

Method. Use any inhaler or handkercnief. When the pain just 
begins pour 2 to 5 drops on the handkerchief and hold over the 
nose. Keep till the pain begins to pass of¥. This can be determined 
with a little experience. i\t the next pain repeat the process. May 
be necessary to put more on the cloth, but see that the patient does 
not inhale too much ; often one or two whiffs enough. 

Obstetric anesthesia is: i. Always intermittent. 2. Never 
complete. 3. Only during the beginning and height of a pain. As 
the labor ends, give more, and at the end of the second stage, while 
the head is coming through, the patient may be almost completely 
under. The mask is then completely removed, and by the time the 
baby cries the woman begins to waken. 

Surgical degree of anesthesia is needed in obstetrics under the 
same conditions as in surgery, to abolish reflex action, to quiet 
patient, to relieve pain. Remember that the same dangers are present 
as in an ordinary surgical anesthesia and the same rules govern you 
here as there. 

The points of treatment in the first stage are : 

1. Antisepsis. 

2. Diagnosis of the case. 

3. Watchful expectancy. 

4. Attention to the bladder and rectum. 

5. Relief of pain. 

Treatment of the Second Stage. 

The patient must await the rupture of the bag of waters on her 
back. Now make an examination, and you will generally have to 
stand ready to deliver the child, wherefore keep your hands clean. 
In primiparae you usually have more time, the second stage lasting 
i>4 to 2 hours. Still, the bag of waters may rupture only when the 
head is w^ell down on the perineum and then the head comes rapidly 
out. Patient may feel as if bowels would move, but do not let her 
get out of bed. Until the head is well down on the perineum keep 
her on her back, or allow her to turn on her side, that side to which 
the occiput points, this favoring rotation. Obstetrician's duty here 
is watchful expectancy also. He must regulate the abdominal press- 



160 NOTES ON OBSTETRICS— JUNIOR CLASS. 

ure. Use the various aids mentioned, — pulling on a sheet or the 
hands of the nurse or husband. 

The question of anasthesia again comes up. May not be neces- 
sary now, as the patient bears down strongly and does not com- 
plain very much, still occasionally needed. Have someone else 
administer it or wrap a bichloride sponge around the bottle and 
give it yourself. Two important points in the treatment of the 
second stage are, the protection of the pevmeum, and the preserva- 
tion of the child's life. Some authors have held that the protec- 
tion of the perineum is unnecessary, that in normal cases the 
perineum does not tear, or tears so slightly that no pathologic signifi- 
cance is to be attached to it. These views arc wrong. A woman 
may be made a life-long invalid from so-called normal labor, the 
perineum may be torn through the anus ; further, these tears may 
almost always be limited and very, very frequently be prevented. 
We, therefore, protect the perineum. 

Reasons are : 

1. The perineum is a "structure of physiological and pathological 
dignity.'^ Extensive rupture of the perineum causes sterility often. 

2. When the rupture occurs in the median line, no one can tell 
where it will end. It may pass through the anus and cause perma- 
nent incontinence of feces. 

3. They may form atria of infection which may be fatal. 

4. Perineal structures once torn cannot be perfectly restored, as 
they almost always shrink after a longer or shorter period of time. 

5. Protection of the perineum is possible; 15% to 20% of primi- 
parae and 5% of multiparae suffer more or less tearing of the 
perineum ; 39% primiparae have a tear of the fourchette. The 
hymen is always torn. In some cases, where the elasticity of the 
perineum is slight, or the head too large, or where the perineum is 
pathologically altered, e. g., edematous, a white-celled infiltration 
from syphilis, condylomata lata, or infiltrated with fat, it will almost 
always tear. These form not more than 15% of cases. Still, in these 
cases the tear can be limited. Other causes of perineal tear even 
when the perineum is not pathologically altered, are exit of the head 
in a bad position, e. g., posterior rotation of the occiput, face presenta- 
tion, brow presentation, breech presentation. Here the necessity for 
rapid delivery of the head exists, and this is the main reason for 
the tear. Small angle of the pubic rami, The levator ani may tear 
from the wall of the pelvis at the side. These are hard to prevent, 
harder to diagnose and impossible to sew up. An early recognition 
and median incision in the levator ani are to be made. 

Method of Protection. 

I. Place patient on the side. Always deliver on the side. Schroe- 
der proved that tears are less frequent with this posture. Reasons 



NOTES ON OBSTETRICS— JUNIOR CLASS. 101 

are, the patient cannot press so hard and, therefore, the head comes 
through more slowly. Again, you can control the escape of the 
head better. Other advantages of the side position are, you can 
see the perineum and observe the beginning of a tear. You have 
the patient in your grasp. There is one strong objection — one can- 
not listen to the fetal heart tones so easily as when the patient is on 
her back. If there is any suspicion of fetal danger, keep patient on 
her back. 

2. Retard Descent till the elasticity of the pelvic floor and peri- 
neum is most developed. When the head becomes visible m the 
vulva, place the fingers near it to see that it does not come down 
too far at one pain. Sit on the side of the bed with one arm over 
the abdomen and the hand betw^een the thighs resting on the pubis. 
If the woman is bearing down too much tell her to stop it, to cry out 
or to breathe hard with the mouth open. As the head comes dowm 
place the finger on it so as to allow it to advance a little further with 
each pain. Be careful not to injure the head by too firm pressure. 

3. Prevent Extension of the Head, i. e., let the head come down 
in forced flexion till the nape of the neck is well against the symphy- 
sis and the parietal bosses have been delivered, then allow the fore- 
head, face and chin to come over the perineum, forcing the whole 
head up on the symphysis as it comes out. 

4. Deliver the Head Between Pains. Hold the head back with 
both hands ; when the last few pains come on, tell the patient to 
open her mouth till pain passes oif, then ask her to bear down while 
you push back the rim of the vulva on each side of the head and 
push up on the head at the point of the large fontanelle. xAfter the 
parietal bosses are delivered, pull the head up and let the soft parts 
slip back over the forehead and face by their own elasticity. Wipe 
the mucus from the mouth and eyes, and wash around the eyes wath 
pledgets wTung dry from the antiseptic solution. This is to remove 
infection from the neighborhood of the eyes. In passing through the 
outlet of the pelvis and vulva, it is important that the smallest diam- 
eters of the head be presented to the girdle of resistance. To ac- 
complish this, the normal mechanism of labor must be adhered to. 
When the head comes dow^n to the perineum, the occiput comes up 
under symphysis. The sinciput may now tend to descend, i. e., the 
chin to deflex, before the occiput is w^ell delivered. This occurs 
in cases, especially where the perineum and vulva are resistant. If 
the head were allowed to come out in this way the largest diameters 
would be presented to the girdle of resistance, i. e., the occipito-breg- 
matic, occipito-frontal, occipito-mental. The perineum would almost 
surely tear. 

If this extension is prevented and the head brought down so that 
the occiput comes out, the nape of the neck presses w^ell up against 
the pubic arch, /. e., flexion is kept up, the nape forms the center, 



162 NOTES ON OBSTETRICS— JUNIOR CLASS. 

and the suboccipital diameters are offered to the girdle of resistance, 
i. e., suboccipito-bregmatic, suboccipito-frontal, suboccipito-mental. 
The gain from flexion varies from i^ to 3 cm. in the various cir- 
cumferences presented. 

Points in the protection of the perineum are : 

1. Deliver in the side position. 

2. Retard descent till elasticity of perineum developed. 

3. Deliver the head in forced flexion. 

4. Deliver between pains. 

Latterly it has been recommended to put the patient in Walcher's 
position during the delivery, it being claimed that this prevents 
perineal tears. Theoretically, it is difficult to see how this position 
can accomplish the stated result, because it diminishes the bony out- 
let, and particularly are the pubic rami brought closer together, 
which forces the head back against the soft parts. The few times 
the writer has employed the method, progress in delivery has been 
distinctly interfered with. The method is very awkward to thne 
accoucheur and painfully uncomfortable to the patient. 

In 85% of the cases the perineum can be saved from rupture, 
but where the disproportion between the head and the vulvar outlet 
is great, or where the vulva is pathologically altered, a tear may 
be unavoidable. To obviate these tears an operation called Episi- 
otomy is sometimes done. This is an incision usually made at the 
side of the vulva about 2 cm. from the raphe, 2 cm. deep, dividing 
skin, muscle and vaginal outlet ; may be uni- or bi-lateral. Or one 
may cut from the median line down along side of anus. This opera- 
tion was devised by Ould, in 1742, for cases where the tight 
perineum offered resistance to the exit of the head. Others since 
perform it to obviate a central rupture of the perineum. Claimed 
that a lateral incision is preferable to a tear in the median line, since : 

1. Cannot tell where the tear will end ; it may involve the sphinc- 
ter ani. 

2. Clean-cut wound ; also further from lochial secretion than cen- 
ter tear. 

3. Importance of the lateral structures of the vulva not so great 
as central. 

There are certain Objections to Episiotomy: 

1. It is usually unnecessary; doing it, one sometimes decides that 
the head would have come through without it. 

2. It may leave painful and deforming scars. 

3. The perineum may tear in the median line, even with lateral 
episiotomy. 

Method of election is that of Tarnier; the medio-lateral. Be- 
gin at the raphe and cut down alongside anus. 
Indications are : 



NOTES ON OBSTETRICS— JUNIOR CLASS. 163 

1. Delay in exit of the head, due to resistant vulva. 

2. Some indication for rapid extraction, by the breech or head. 

3. Posterior rotation of the occiput in primiparae, or brow 
presentation, /. e., when large diameters of head necessarily pre- 
sented. 

4. Some pathological condition of the soft parts, e. g., Syphilis. 
In operative deliveries rupture is very frequent and episiotomy 

often needed. Note when the vagina begins to part. Place one blade 
of the scissors in the wound, the other blade as indicated in the fig- 
ure, and cut the perineum. 



As your experience grows you will make less and less use of 
episiotomy, but you had better use it in your first cases, when, in 
your judgment, there is danger of a deep perineal tear. After the 
labor the wound is closed with silk-w^orm gut sutures. 

After the head is born pass the finger up over the neck to see 
if the cord is around it. If it is, draw a short loop, or loosen the 
cord a little. Wipe the mucus from the face, mouth and nose. Use a 
cotton pledget squeezed dry from an antiseptic solution for the face. 
Tell the patient to bear down hard, or have the husband press on 
the fundus uteri, or you may do it yourself with your elbow. There 
need be no great hurry to deliver the trunk. A few minutes may 
safely intervene if the face reacts to external stimuli, e. g., blowing 
on it. 

Delivery of the Shoidders. 

Usually after a minute, the anterior shoulder is visible, just 
behind the pubis, the patient bears down, and the posterior shoulder 
rolls over the perineum. If there should be any delay, turn the pa- 
tient on her back, which can always be easily done. If the efforts 
of the woman and pressure on the fundus do not deliver the shoulder 
speedily, make very gentle traction on the head down toward the 
perineum till the anterior shoulder is well under the symphysis, the 
arm stemming behind it. Then change the traction so as to bring 
the posterior shoulder out, then pull the anterior shoulder from 
under the pubis. Do this slowly and gently so that you do not tear 
the perineum or fracture the child's neck or clavicle. A perineum 
slightly torn by the head may be ploughed deeply by the shoulders. 
Do not drag the child out of the uterus, let the natural powers force 
it out if possible. The rest of the child follows in a very few sec- 



164 N07ES ON OBSTETRICS— JUNIOR CLASS. 

onds, aided by the expulsive efforts, or slight traction exerted on the 
trunk. 

There is a rush of liquor amnii, and the uterus contracts down 
to a hard ball, the size of a cocoanut. Turn the patient on her 
back now, very slowly, keeping a hand on the uterus all the 
time, and legs close together, to prevent air embolism. See that 
the baby is not crushed. Place the child just so far that it will 
not kick the vulva, but near so that it will not draw on the cord. 
After a few moments the baby cries. At first, if you observe care- 
fully, you will see several light inspiratory efforts, then one or two 
deep ones, and then comes the cry or sneeze, or a cough, which 
empties some mucus from the pharynx. The child at first is 
more or less blue, cyanotic, but after a few respirations, the color 
gets better. Wipe the mucus from its pharynx with a soft cloth 
wrapped around the finger, or suck it out with a tracheal catheter. 
While waiting to tie the cord, wipe the face and forehead with 
pledgets squeezed dry from the lysol solution. This is to prevent 
vaginal secretions on the face from obtaining access to the eyes. 
May now flush the eyes with boric solution poured from a bottle or 
from a medicine dropper. 

The asepsis and antisepsis are carried out with great minute- 
ness during the treatment of the second stage. The woman is placed 
on her side at the edge of the bed, on sterile sheets, covered with a 
sterile sheet ; she has on sterilized cotton long hose. Between the 
knees a pillow, pinned in a sterile pillow-case. The vulva and but- 
tocks are washed again thoroughly with i/iooo bichloride or i% 
lysol, and the accoucheur's hands are again sterilized, and they must 
be kept sterile throughout the entire delivery, which is not always an 
easy matter. All discharges from the vagina and the rectum, par- 
ticularly the latter, must be washed off carefully with pledgets of 
cotton or gauze wrung out of antiseptic solution, taking exceeding 
care not to wipe anything over or into the genitals. The necessary 
articles, basin, towels, ligatures, scissors, etc., should be close to the 
bedside, and means should be provided for the revival of the child 
and the treatment of post partum hemorrhage. 

The second part, requiring great watchfulness during the second 
stage, is the life of the child. Every 15 to 20 minutes the fetal heart 
tones are counted, and other signs of asphyxia studied. See chapter 
on Asphyxia. 

The Cause of the First Respiration. 

Subject of great interest. Many theories. One, that of Preyer, 
that the irritation of the skin from the trauma of labor causes the 
respiration by stimulating the respiration center reflexly. This is 
not probable. The child in utero exists in a state of apnea. Stim- 
uli applied in this condition have no effect on the fetus, shown by 



NO'inS ON OBSTETRICS— JUNIOR CLASS. iGo 

rough palpation, attempts at version, forceps, etc. Should the child, 
however, be partly asphyxiated, the respiratory center will react to 
these stimuli. The theory that the exposure to cold (when the 
child is born), causes the respiration, has only an influence of sec- 
ondary importance. Ahlfeld delivered several children into warm 
saline solution. The respiration began as usual. Again, sometimes 
a half minute will elapse before the first respiration occurs, and re- 
flex should be quicker than this. The most accepted theory is that 
the gradual hypercarbonization of the blood makes the respiratory 
center more irritable. This occurs in the latter months of preg- 
nancy, due to the gradual narrowing of the ductus arteriosus and 
venosus. During labor this is increased. When the child's head 
is born the placenta is beginning to separate, and when the baby is 
delivered, the placenta is almost completely separated. As a result, 
the fetus passes fr^om a condition of apnea to one of dyspnea, the 
respiratory center is irritated and causes respiration. The same con- 
dition occurs in utero w^hen the placental circulation is cut of¥. When 
the respiratory center is thus more irritable, any external stimulus 
will have a greater effect. 

During pregnancy the blood from the placenta, after being oxy- 
genated, returns to the fetus by the way of the umbilical vein. It en- 
ters the liver, dividing into three parts. One enters the liver direct- 
ly, one meets the stream from the portal and with it enters the 
liver ; the third passes on into the vena cava ascendens through the 
ductus venosus Arantii. Here the blood from the hepatic veins 
enters with the stream returning from the legs. This blood is pro- 
jected into the left auricle and then the ventricle, and is sent through- 
out the body, the larger part leaving by the way of the hypogastric 
arteries for the placenta. 

The blood from the head descends in the vena cava descendens 
directly into the right ventricle. From here it is pumped into the 
pulmonary artery to the lungs. But these are so poorly developed 
that they can take little of it. It therefore takes a short cut to the 
aorta through the ductus arteriosus Botalli and goes down the aorta 
with the blood from the left ventricle. At no point is the blood 
arterial. The liver grows faster than the ductus venosus, so that as 
pregnancy goes on, less and less blood passes through this vein. The 
lungs develop more as pregnancy goes on and, therefore, use more 
of the oxygen and the blood which comes from the pulmonary artery. 
The ductus arteriosus Botalli, therefore, grows smaller. The re- 
sult of the two factors is that the blood grows more venous in the 
latter weeks of pregnancy. 

After the birth of the child and the cessation of the placental 
circulation important changes take place. With the first inspiration 
the lungs expand. The pulmonary vessels are dilated and blood 
rushes into them from the right ventricle. There is no blood to pass 



166 NOTES ON OBSTETRICS— JUNIOR CLASS. 

through the ductus BotalH. It, therefore, contracts, collapses. There 
is less blood coming from the ascending vena cava (the umbilical 
vein contracting), the pressure in the right auricle sinks. The 
result is an aspiration toward the heart of the blood in the vena cava 
and umbilical vein. Tlie hypogastric arteries contract and throm- 
bose. This is due to the fact that the left ventricle cannot send 
the blood the long distance through them, since it is no longer as- 
sisted by the right ventricle through the ductus Botalli. Also, cold 
contracts the arteries. The pulsation in the cord ceases. 

The circulation is now just the same as in the adult. The 
ductus Arantii and Botalli get smaller by contraction of their muscu- 
lar fibres, and the walls are applied to each other. No thrombosis 
occurs in them or in the vein of the umbilical cord (only in the 
arteries). They become obliterated in one or two weeks. 

An important question is, when to tie the cord? Formerly the 
custom was to tie the cord as soon as the child is born. Now not so. 
Immediately after the child is born, it is subjected to atmospheric 
pressure. It is claimed that the pressure in the uterus at this time 
is somewhat below that of the atmosphere, and that, therefore, the 
blood of the child may be aspirated into the placenta. There is 
great doubt about this. We" know that during the first minutes after 
birth the child gains weight, which comes from the blood which 
it gets from the placenta. This is determined by letting a child lie 
on a scale, after it is born. Accurate weighings have shown that the 
fetus of 3,000 grammes has about 158 gms. (Welcker) of blood 
(1/19 its weight). It may gain 39 grammes of blood. 

It is believed by some that the blood is aspirated by the lungs of 
the fetus. The sudden dilatation of the chest is said to cause decrease 
in the intra-thoracic pressure and that, therefore, the blood in the 
venae cavae and umbilical vein rushes to the chest. A certain dimi- 
nution of the pressure is certain because of the development and un- 
folding of the pulmonary vessels. But a dimunition that would aspi- 
rate blood in such a large amount to the child is very improbable; 
further, at post mortems on young infants, the lungs do not collapse 
after opening the chest, shqwing that the intra-thoracic tension is 
not minus. 

It is probable that the pressure to which the placenta is sub- 
jected by the uterine contractions forces the blood from the placenta 
to the fetus. It is claimed for the late tying of the cord that the 
children lose less weight in the first days and grow better, and are 
less likely to have sepsis. Argued against the late tying of cord, 
and especially against the custom of pressing toward the fetus, all 
the reserve blood in the placenta, that icterus neonatorum, melena 
neonatorum, even apoplexy are likely to result. We, therefore, in 
tying the cord take a middle position and wait a few minutes till 
the pulsation of the cord has ceased, or at least weakened, before 



NOTES ON OBSTETRICS— JUNIOR CLASS. 167 

placing the lig-ature. Tie the cord tightly about one-fourth inch 
from the navel with sterilized tape. Take a few minutes to do it, 
so that the jelly of Wharton can be completely pressed away, and 
the vessels surely compressed. Then tie an inch or two toward the 
maternal side and cut between the ligatures, one-fourth inch from 
the first, the cord lying in the hand. See that no part of the fetus 
is cut or tied during the operation. 

The practice of tying the cord close to the skin is only recent. 
It has the advantages, ist, leaves a small stump, less to become in- 
fected : 2nd, it is easier for the nurse to dress, and is less liable 
to be pulled upon when the infant is handled ; 3rd, the cord drops off 
earlier, usually by the fourth day, often on the third, which is two 
to four days earlier than with other methods. The precaution must 
be insisted on, a careful inspection must prove that there is no 
hernia into the cord. Use sterilized tape or what is known as 
''bobbin," impregnated with nitrate of silver ; or simply sterilized, 
and soaked in lysol solution. 

The new-born child is more susceptible to infection than the 
adult. The navel forms the most frequent atrium for the infec- 
tion, being more or less of an open wound for 3 to 10 days. Arte- 
ritis, phlebitis, suppurative hepatitis, sepsis, pyemia and tetanus 
are all caused by infections of the navel. Therefore, dress the cord 
carefully. Tie with sterile cord and hands ; do not allow the baby 
to be wrapped in a dirty shawl. Sterilize the stump with 1% 
lysol, and w^ap in dry cotton or sterile gauze or borated gauze. 
Do not allow the cord to get into a moist condition, but favor mum- 
mification, as sepsis less likely to occur when the cord is dry. 

The points in the treatment of the second stage are : i. Asepsis 
and antisepsis. 2. Anesthetic. 3. Protection of perineum. 

The establishment of respiration, the ligation of the cord, the care 
of the eyes, belong to the treatment of the 3rd stage. 

The Care of the Eyes. 

Prevention of ophthalmia neonatorum. This is an acute, purulent 
inflammation of the conjunctiva, due almost always to the Gonococ- 
cus of Neisser, and causing frequently total blindness. It is in the 
highest degree preventable. Even in lying-in hospitals, where a 
large number of the cases treated suffer with gonorrheal vaginitis, 
the disease has been eradicated. The germs get into the eyes with 
the vaginal mucus during the passage of the head through the vagina 
and set up the inflamm.ation in the conjunctival sac. Other germs 
may cause the inflammation, e. g., diphtheria bacillus, pneumo- 
coccus. 

Prevention. 

As soon as the head is born, wash face with a sponge Avrung 
dry from lysol or HgCl2 : waiting for the tying of the cord, flush 



168 NOTES ON OBSTETRICS— JUNIOR CLASS. 

the eyes again with saturated boric solution from a bottle. Separate 
the lids very gently, or the baby will open the eyes if the liquid is 
gently poured on the lids, warm from the bottle. As soon as the 3rd 
stage is over put one minim of a 1% solution of AgNo3 in each eye 
and then a few drops of salt solution. This is routine in every case. 

If you suspect the woman has gonorrhea use the Crede method of 
treatment of the eyes. One minim of a 2% AgNo3 solution is 
dropped into each eye, and then neutralized with a weak saline solu- 
tion. A vagmal douche, 1% lysol, should in such cases be given 
before labor, and repeated every 8 hours if the labor be long. (Sec- 
ond point in the prevention of opthalmia neonatorum.) Let the 
bag of waters rupture as late as possible, so that it covers the vagina 
as the head comes down. In cases of condylomata of the vulva, or 
vagina, or where there is a purulent, greenish discharge, or where 
you have demonstrated the gonococcus, or know the husband has 
gonorrhea, be on the lookout for ophthalmia, ]\Iost hospitals use 
the Crede method in all cases, as a routine practice. Protargol and 
argyrol are also used. Pay attention to the first bath, see that no 
w^ater gets into the eyes, or that the baby does not get its hands 
to the eyes. In preference to the bath, oil the baby all over with 
olive oil or albolene, or lard. 

After the baby's eyes are attended to and the cord severed, it is 
handed to the nurse, who wraps it up in a warm "receiver" and puts 
it near the stove or register. It should not be allowed to become 
cold. 

TREATMENT OF THE THIRD STAGE. 

Treatment of the third stage is highly important, as on it will 
depend the freedom of the woman from post partum hemorrhage, 
and also the nature of the puerperium, and even her health later in 
life. It is equally as important as the second stage. 

After the birth of the child have a hand lie on the uterus ; it should 
not rub, but simply lie there. While you attend to the cord the hus- 
band or nurse does this. After the baby is attended to, place a warm, 
clean folded sheet under the patient, draw the cord over one thigh, 
leaving a short loop, the length of which you note. Place a sterile 
basin under the buttocks, so as to receive all the discharge from the 
vulva. Inspect the vulva for tears and note the presence of hemorrhage. 
If there is none, draw a sheet over the patient, sit down beside the 
bed, with one hand on the uterus and the other on the pulse. Every 
two or three minutes raise the sheet and look in the basin to see 
if blood is accumulating there. Watch patient's color. Hand rests 
on uterus to determine the degree of retraction and the frequency 
of the contractions. If the uterus is hard in a normal labor almost 
always there is no hemorrhage, but if an operative case, you must 



NOTES ON OBSTETRICS— JUNIOR CLASS. 1(59- 

watch for external hemorrhage from some injury of the genital 
tract. No necessity to massage the uterus in a normal case. Two 
indications for uterine massage : ist. If there is external hemor- 
rhage. 2nd. If you feel the uterus get soft and balloon out under 
your hand, rising above the navel. In from 5 to 25 minutes the 
three signs are present to which your attention was called : 

I. The cord becomes limp and advances 3 or 4 inches from 

the vulva. 
II. The uterus rises high in the abdomen, usually to the right 

side, while below, over the symphysis, it is soft and 

boggy. 
III. The uterus flattens and has a sharp upper border. These 

mean that the placenta has left the uterine cavity and has 

slid down into the lower uterine segment and upper part 

of the vagina. 
Wait 25 to 45 minutes before expelling the placenta. Often it 
comes of itself, while you wait, or the woman forces it out. At the 
end of this time, place the whole hand on the uterus, standing to the 
side, four fingers behind, thumb in front. First make sure the 
bladder is empty. Wait for a contraction. See that the uterus is 
in the median line. If the uterus is to the side push it to the median 
line. If it is not contracted, massage till it gets hard. Now press 
down toward the inlet of the pelvis, holding the uterus fast. The 
uterus is used simply as a body through which to exert pressure 
on the placenta, and this maneuver is called ^' early expression/' 
early, because it is done before nature would express the placenta. 
After placenta is extruded, grasp it in the full hand, rub uterus 
evenly with the other hand, and gently exert traction on the mem- 
branes. Do not pull too hard or too fast on the membranes, because 
they will tear. Better to let the membranes come themselves than 
to draw on them so that they break. 

If the placenta does not come with the simple pressure, and you 
can tell that at the time, you may use the Credc Expression. The 
uterus is grasped as before, but while pushing it bodily toward 
the outlet of the pelvis, in a line with the axis, you squeeze the 
uterus together, the thumb on the palm, i. e., you squeeze the pla- 
centa out "like the pit from a cherry." If this should not suc- 
ceed with moderate pressure, wait 10 to 15 minutes. You may 
be sure that the third stage is pathological. After this time try 
again the Crede Expression. If not successful, wait 30 minutes. 
There is no danger as long as there is no hemorrhage, external 
or internal. You can wait 2 to 2^ hours with no danger to mother. 
What to do if the woman bleeds? Rub the uterus well. Fingers 
behind, thumb in front. Keep up the massage till the uterus is a 
hard ball under the hand. If hemorrhage now ceases completely no 
need to express the placenta, but w^ait, watching the uterus. If it 



170 NOTES ON OBSTETRICS— JUNIOR CLASS. 

begins to relax, massage. If the oozing starts up, use the Crede 
expression, bearing in iliind : 

1. Uterus must be in the median Une. 

2. Uterus must be contracted. 

3. The bladder must be empty. 

In the treatment of post partum hemorrhage we will revert to 
this subject. After the placenta and membranes are born one may 
give the patient dr. i of ergot. Never give it while there is any- 
thing IN the uterus. In primiparae, it is not necessary, but if 
3^ou have no one to take care of the patient and you live at a dis- 
tance, give it here. In the hard-working peasant women ergot is un- 
necessary and may cause severe after-pains, if she is a multiparae. 
Other methods of treating the 3rd stage have been employed. The 
oldest is the practice of traction on the cord. Two fingers are passed 
along the cord to the placenta, traction is now made with the other 
hand, the placenta being forced into the hollow of the sacrum by 
the internal hand. Method unqualifiedly bad. 

Objections : 

1. If the placenta is adherent or simply incarcerated, it is inef- 
ficient. 

2. It may produce inversion of the uterus. 

3. Cord may tear ofif, leaving the placenta adherent. 

4. Too much fingering in the vagina (infection). 

5. No control of the uterus. 

Up to 1 86 1 this method generally practiced, even now there are 
some doctors who practice it. 

In 1861 Crede, of Leipsic, formulated this method : 

1. After the baby is born, massage the uterus until the first after- 
pain. 

2. Press the whole uterus down toward the inlet and squeeze the 
placenta out at the same time. 

Objections are: ' 

1. It is not physiological. 

2. Too rapidly emptying the uterus. 

3. Hemorrhage is greater than with the method just given at 
length. 

4. Retention of the membranes, especially the decidua, is more 
frequent. Also retention of pieces of placenta. 

5. Bruizing of the uterus may result. 

For many years before this there was practiced in Dublin a 
procedure similar to Crede's, except that the time allowed for the 
expression was longer, called the Dublin method. 

In 1880 Dohrn, and since 1882, Ahlfeld, have called attention to 
the objections to the Crede method and have proposed a purely ex- 
pectant treatment of the 3rd stage. 



NOTES ON O^STETJtlCS— JUNIOR CLASS. lY] 

Ahlfeld's Method. 

After labor the hands are kept away from the uterus, but the eord 
put over the thigh and legs crossed. Dr. sits at the side of the patient, 
•controls pulse and countenance, occasionally looking under the bed 
clothes to see if hemorrhage is occurring. 

After two hours the woman is told to bear down, or the placenta 
is gently expressed in the manner indicated. V^ery often the placenta 
wall be spontaneously delivered during the 2 hours. Still it may not, 
and in the absence of art might stay in the genital tract till it putri- 
-fies. As a rule, it is expelled in 3 or 4 hours. 

Claimed for the expectant treatment that the loss of blood is 
less, that the tearing of the placenta and membranes is less, that the 
decidua is almost always delivered complete, and that the puerperium 
IS not so likely to have slight rises of temiperature. All these state- 
ments are not true. The average loss of blood with the expectant 
treatment is 400 to 500 gms. With the treatment I have given you 
it is less than 200 gms. With Crede's method it is 400 to 6cxD gms. 

Objections to the expectant treatment are: 

1. Loss of blood is greater than is necessary and may be dan- 
gerous to a small, anemic woman. 

2. Keeps the woman in an anxious condition too long. 

3. Takes too much time. 

The treatment, therefore, of election is a combination of the two, 
one that embraces good points of both and avoids the bad ones. It 
is the one described at the beginning of this chapter. 

1. Hand on the uterus after babv is born, no massage, but con- 
trol. 

2. After 35 minutes tell the patient to bear down. If not suc- 
cessful, 

3. Press the placenta out gently, grasping the uterus in the whole 
hand, early expression. Remember three points : 

Uterus contracted. 
Uterus in median line. 
Bladder empty. 

4. If uterus bleeds of gets too large and soft, massage. 

5. If simple expression unsuccessful, use Crede Expression. 
Now examine the placenta carefully to see if it is complete. Make 

the examination minutely and systematically. 

I. The IMembranes. See that they are complete, noting the size 
of the opening. May fill them with water. If there are tags try to 
re-adapt them in place. If they are torn from the edge of the pla- 
centa, see if they will fit to it. If not, may be sure that part of the 
membrane is retained. See if amnion is complete, then chorion. If 
there is a piece of chorion missing, the decidua with it will also be 
missing. 



1V2 NOTES ON OBSTETRICS— JUNIOR CLASS. 

2. The Placenta. Maternal Surface. Look around the edge.. 
See if all the cotyledons are there. If a tear, see if the parts will 
fold together. If the edge is even all around almost always the 
placenta is complete, seldom that a piece is missing from the center- 
Notice if the decidua serotina is unbroken all over, see if there is 
not some defect. If the edge of the placenta is ragged suspect that 
a placenta succenturiata exists. 

3. The Fetal Surface. Notice the course of the vessels. If they 
get too small to see, before reaching the edge, or if they break off 
suddenly at the edge. This means that there is a piece of placenta 
missing. If the membranes are not complete, leave them, if you 
have been clean. If there is a piece of placenta missing, larger than 
an English walnut, go in, with the fingers, and take it out, under 
rigid antisepsis. If smaller, leave it alone. If it causes hemorrhage, 
it must be removed, however small. Use sterile gloves. 

Care of the Baby. 

Formerly, and to a large extent still, the custom to bathe the 
baby, after annointing it with lard or fat, to remove the vernix 
caseosa. By this process the child often gets blue, cold and chilled ; 
further, many of the skin eruptions to which the children are Hable 
come from the bathing. A better practice is to oil the baby with 
olive oil or albolene from head to foot, and then wupe this off with 
a soft linen towel. Pay particular attention to the creases because 
the vernix accumulates there. Be careful not to get anything into 
the eyes. After the baby is dried, sterilize the cord with 1/2000 
HgCl2, or lysol solution, and wrap it in borated gauze, or sterile 
cotton. Then apply the binder loosely, turning stump of cord up- 
ward. 

Before leaving the house there are 7 things to do : 

1. See that the uterus is in a state of tonus, /. e., well contracted, 
and that there is no inversion of the uterus (rare, but does occur). 

2. See that the bladder is not distended. 

3. See that there is no hemorrhage from the vulvar orifice, and 
no infernal hemorrhage. 

4. See that all perineal and vulvar tears are attended to. 

5. See that the placenta and membranes are complete. 

6. See that the baby is in good condition, no mucus in throat, no 
hemorrhage from cord. 

7. See that the woman is in good condition, no high pulse, no 
headaches, no vomiting, etc. Think of eclampsia, of internal hemor- 
rhage. 

If a perineal tear, it must be sutured. If slight or if vulvar tears, 
they may be dressed antiseptically. If kept clean they heal kindly. 
The nurse usually applies the abdominal binder to the woman ; there 
is no objection to this, unless it be applied too tightly. It relieves 



NOTES ON OBSTETRICS— JUNIOR CLASS. 173 

the empty feeling after the abdomen is emptied and tends to prevent 
syncope. AppHed too tightly it forces the uterus down into the 
pelvis and may favor prolapsus uteri. 

Stay in the house a full hour from the time the placenta is born, 
longer if you have the time. You must leave accurate (preferably 
written) instructions with the nurse, what to do in case of post 
partum hemorrhage, also a list of the places where you intend to 
go, so that you can be gotten in a hurry, if necessary. 

Let us pause here to take a glance back at the treatment of labor 
as a whole. It should be regarded as a surgical operation ; it really 
is such, and the obstetrician is really a surgeon. He considers every 
labor, therefore, first, as to the ability of the patient to stand the 
shock : second, to arrange for asepsis and antisepsis ; third, he care- 
fully watches for and provides against complications. 

During the labor the accoucheur observes the powers and esti- 
mates the resistances, judges whether the powers are sufficient to 
overcome the latter ; he watches the mechanism of labor as its va- 
rious phases pass under the eye and hand ; he is always alert to any 
abnormality in the mechanism, and keenly alive to the possibility of 
some outside compHcation occurring, which may throw either or 
both patients into acute danger. Through all he throws around both 
patients the protection from infection which, of recent years, has 
become almost perfect. 

The conduct of labor is not a simple matter, safely entrusted to 
•everyone. Let the people know that having a child is an important 
affair, worthy of the deepest solicitation on the part of the friends, 
needing the watchful attention of a qualified practitioner, and that 
the care of even a normal confinement is worthy the dignity of the 
greatest surgeon. 

UNUSUAL :\iechaxis:m of the head, deflexion 

ATTITUDES. 

In certain labors the head enters the pelvis wnth the sagittal 
■suture parallel with the transverse diameter of the pelvis. Sutugin, 
of Russia, claims that the majority do this. The head usually flexes 
and enters the pelvis flexed, then rotates so that the occiput comes 
anteriorly : i . In certain cases the head does not flex, but comes 
<low^n to the perineum with the large fontanelle, nearly on a level 
with the small fontanelle. This is called the military attitude. In 
these cases rotation does not take place till late, or may not occur at 
all. This condition is spoken of as deep transverse arrest of the 
head. 2. Again, the head comes into the pelvis in the oblique, but 
with the occiput directed posteriorly. O. D. P., O. L. P. If the 
head does not flex well, of if pains are not strong enough to rotate 
the occiput, the whole 135 degrees, so as to bring it anteriorly, it re- 



174 NOTES ON OBSTETRICS— JUNIOR CLASS. 

mains in the transverse diameter of the pelvis and we have the same 
condition as before, deep transverse arrest, i. e., the head is arrested 
ni rotation, when it is deep in the pelvis. 

Causes. 

Both these cases are caused by : 

1. Flat pelvis, the occiput meets with resistance sooner than the 
sinciput, therefore, no flexion. 

2. Failure in the powers of labor. Uterus. Abdominal pressure.. 

3. Both ends of the head lever of the same length, i. e., the sin- 
cipital end equals the occipital, called dolicocephalus. 

4. Pendulous abdomen, back is at an angle with the head. 

5. Prolapse of the arm alongside of the head, if arm before the; 
occiput. 

Fmdings. 

Abdominally, the same as in occipito-posterior positions. (See 
later.) Vaginally, head deep in pelvis or a little lower than the 
mid-plane. Sagittal suture in transverse diameter of the pelvis^ 
fontanelle to one side, small fontanelle to the other, both in the same 
plane. Head seems to be wedged in between the two rami of the 
ischia. Sometimes referred to as impaction. 

Course and Terminations. 

I. After remaining some time, flexion may occur, and the 
occiput may rotate anteriorly, and later terminate spontaneously. Re- 
quires strong pains. Usually the child is small. 

11. Head may come out in the transverse diameter. Requires 
strong pains, large and soft passages, small child. 

ni. Occiput may rotate to the hollow of the sacrum. 
Then there are two mechanisms in the latter event. 

(a) Large fontanelle may sink lower than the small one and take 
the line of direction, rotating anteriorly, that is, deflexion occurs. 
These are called forehead presentations. 

(b) Occiput comes over perineum with the head well flexed. 

Second Umisiial Mechanism of the Head. 

It occasionally happens that the head enters the pelvis with the 
occiput posteriorly, and that this is kept up till the head reaches 
the floor of the pelvis. Instead of turning to the front the occiput 
remains posteriorly, or may even rotate into the hollow of the sacrum. 
These cases are called posterior rotation of the occiput. Sometimes 
occipito-sacral positions. When the occiput rotates to the sacrum 
and the sinciput comes down the front, they are called forehead' 
presentations. 



NOTES ON OBSTETRICS— JUNIOR CLASS. 175 

This is one of the terminations of deep transverse arrest, and 
occurs 1 in 75 cases (Kehrer). 

The causes of occipito-posterior positions or forehead presenta- 
tions are : 

1. Flat pelvis. Here the occiput meets with resistance first; 
therefore, the two arms of the lever meet unequal resistance, flexion 
does not occur. 

2. Extra large pelvis, or small child. The second twin very 
often comes in this position. 

3. The sincipital end of the head lever equals the occipital end^ 
primary dolicocephalia. 

4. Pendulous abdomen, the convex back of the fetus fits much 
better to the posterior surface of the uterus. 

5. Prolapsus of an arm alongside of the head. This mechani- 
cally prevents the occiput from rotating anteriorly. If the case was 
O. L. A. and the posterior arm down, prolapse will have no bad ef- 
fect at all, rather facilitate the rotation. 

6. Exhaustion of the powers before rotation completed. Rotation 
takes place in part, powers give out. 

7. Interference, during which the occiput rotates to the sacrum. 
The position of the placenta may give the back an unusual situs. 
Tumors and scars in the uterus by altering its shape. Not all causes 
are known or fully explained. We have two forms of occipito- 
posterior positions : 

1. That where the occiput is behind from the start, the fore- 

head becoming the point of direction. 

2. That where the case is one of deep transverse arrest, and 

an anomalous rotation took place. Etiology not clear. 

In the first form we find the head high up, the small and large 
fontanelles on a level. This is sometimes called the military atti- 
tude, or median vertex presentation. The large fontanelle may be 
lower, i e., the deflexion has increased to a marked extent. Now, if 
the deflexion goes still further, the brow will be the point of direc- 
tion, and we will have a hrow presentation. If it goes further still, 
the face will come over the inlet, and we will have the last of the 
so-called "deflexion-positions," a face presentation. Thus, you see 
the three presentations, forehead, brow and face are simply varia- 
tions of the degree of deflexion of the chin. 

At the beginning of labor (we will take O. D. P., for example), 
we will find the sagittal suture in the transverse diameter, the large 
fontanelle to the left, the small in the right and behind. 

In the course of labor it may happen that the occiput descends 
and rotation anterior takes place, but if this does not occur, the 
large fontanelle takes the line of direction {i. e., the axis of the pel- 
vis). It descends, the forehead meets with the anterior inclined 



176 NOTES ON OBSTETRICS— JUNIOR CEASS. 

plane of the pelvis. Rotation of the forehead anteriorly occurs, the 
occiput going to the sacrum. Xow the perineum bulges strongly, 
the brow stems behind the symphysis pubis, and under powerful 
pains the occiput rolls over the perineum. After the occiput es- 
capes, the nape of the neck is applied to the perineum, and then the 
face comes out from behind the symphysis. The delivery of the 
rest of the body is usually the same as in occipito-anterior position, 
but there is likely to be an increase of the rotation in external resti- 
tution. Extreme flexion takes the place of 4th movement of anterior 
position (extension). 

The delivery is much more painful, tedious and requires stronger 
uterine contractions, and aid from the abdominal muscles. Reasons 
are : 

1st. The greatest circumferences of the fetal head have to 
pass the vulva. Instead of sub-occipito-bregmatic, sub-occipito- 
frontal diameters, there are occipito-frontal and occipito-mental. 

2nd. The nape of the neck is stretched, the chin being strongly 
pressed on the sternum and the back has to enter the pelvis and 
pass through the outlet, as the occiput goes over the perineum. 

3rd. The fetal axis pressure works thus at a great disadvantage 
as regards power, and directly against the perineum ; therefore, the 
tendency for the perineum to tear is quite marked, and this is almost 
always the case in primiparae. 

Operative termination of the labor is very common if the fetus 
is large. Since in one-half the cases the fetus is small, on the w^hole, 
aid is seldom needed. One is sometimes surprised in protecting the 
perineum to find the face coming behind the pubis and the occiput 
coming over the perineum. Or it may not be recognized till after 
the head is born. These labors are usually in multiparae with small 
children, or the parts are so large or the fetus so small that no 
mechanism is necessary for the passage of the head through the 
pelvis and labor is not delayed ; on the contrary, may be very rapid. 

The 2nd form of occipito-posterior position where the occiput ro- 
tates toward the sacrum from a position of deep transverse arrest 
may terminate, either by the forehead stemming behind the pubis and 
the occiput coming over the perineum, or the head may be well 
flexed ; the occiput will then come over the perineum till the nape 
of the neck sinks on it, then the forehead and face come from the 
vulva. Labor is slow only in the primiparae, or where the head 
is of normal size. The danger to the perineum is as great in the lat- 
ter variety, but this is not the commoner method. 

The maternal and fetal mortality is higher than in ordinary head 
presentation, especially the fetal, since the 2nd stage is very long, 
and the uterus is much stretched, the fetus being extended, and 
premature separation of the placenta is more likely to occur. Mor- 
tality, according to Hecker, is 9%. 



NOTES ON OBSTETRICS— JUNIOR CLASS. Ill 

In occipito-posterior position the labor is generally longer, slower, 
the pains being weak, irregular. This is so common that a delay of 
this kind is presumptive of this position. The bag of waters often 
ruptures early, and in general things do not go smoothly. The head 
stays high up, longer than in anterior positions ; stronger pains are 
necessary to bring it well down into the pelvis, and after anterior 
rotation has been started, the uterus and abdominal pressure may 
prove unequal to the task of forcing the head all the way around. 
The labor, therefore, comes to a standstill, the woman does not use 
the abdominal muscles, the uterus acts feebly. This is so-called 
uterine inertia, but it is as much weakness of the abdominal 
muscles. Unless aid is given the uterus may rupture, the child may 
die, or vesico-vaginal fistula result from long pressure of the head 
against the soft parts. 

Treatment. 

As will be seen from the study of the cases, one of the main rea- 
sons that the occiput does not rotate properly is that flexion of the 
chin on the sternum does not occur, or persist. (Hodge.) Our efforts 
therefore must be to aid and keep up "flexion." 

Another reason is that the back does not rotate to the front. 

1. When the head is high up, not fully engaged, let the woman 
walk around, or lie on that side to which the occiput points. Re- 
member, that O. D. P. positions are physiological, that gravity alone 
can produce this position. Therefore, watchful expectancy at this 
period. ]\Iost you can do is to put her on the right side, or left, if 
the occiput be directed to the left. By this means the breech is 
thrown over to the side on which the occiput lies, the spinal column 
is straightened, and the occiput is forced down. This increases the 
flexion and, therefore, rotation is favored. 

Be careful not to rupture the bag of w'aters, as this interferes 
witli the mechanism of labor and usually aggravates the condition. 

2. After the head has engaged, and in spite of the good, strong 
pains, the rotation of the occiput anteriorly does not occur, keep the 
patient on the side. Wait patiently because rotation almost always 
occurs. ]\Iay try the knee chest posture. 

I. Hodge's maneuver. During the pain press up on the sinci- 
put. This causes flexion and, therefore, rotation. Failing in this : 
n. Tarnier's procedure. Pass the fingers behind the ear, and 
during a pain try to rotate it forward, pressing the forehead to the 
back with the hand on the abdom.en. 

ni. Pass the half hand in and try turn the head. All these 
should be done gently ; don't persist in them if they require too 
much force. Use the external hand to operate on the breech and 
shoulders. The inside handTmay push over the shoulder also. Fail- 
ing all three, use the forceps. (See next year.) 



1V8 NOTES ON OBSTETRICS— JUNIOR CLASS. 

Face Presentation. 

Face presentation occurs i in 200 cases ; 232,637 analyzed 
presentations gave i to 198. If the face is the part touched by the 
examining finger, i. e., bounded by the girdle of resistance, we speak 
of a face presentation. 

In the face presentation, the chin is the point of direction, and 
we distinguish the same positions as in occipital positions. 

1. Chin to left and front, Mento-laeva anterior. 

2. Chin to right and behind, Mento-dextra posterior. 

3. Chin to left and behind, Alento-laeva posterior. 

4. Chin to the right anterior, Mento-dextra anterior. 
Frequency of the various positions varies in different statistics. 

In general, they are as above given. But one very seldom observes 
the 3rd and 4th. Why? 

Causes. 

Primary and Secondary. 

Certain causes acting during pregnancy may even bring about a 
face presentation in the latter weeks. These are called primary 
causes, and are : 

1. Movements of the neck muscles and the adaptation of the 
lower uterine segment to the head in a deflexed position. 

2. Hydramnion. Experiments by a Frenchman named Blanc, 
show^ that in a large quantity of water, the fetus sinks to the bottom 
with the head deflected. 

3. Congenital goitre. 

4. A very fat baby. 

5. Tumors of the occiput. 

6. AnencephaHa. ''Snout-labors" (Ahlfeld). 

Certain factors cause a deflexion of the head during labor. Such 
are the secondary causes. 

1. Contracted pelvis. 

2. Dextro-version of the uterus, and obliquity of uterine axis to 
the inlet. 

3. Placenta previa (rare). 

4. Tight cervix (rare). 

In general, it is said that the face cases are usually large children, 
but this is denied by the author. 

Attitude of Fetus. 

The head is completely extended on the back, the forehead is 
flattened, the occiput long drawn out. The neck is stretched, some- 
times there are cracks in the skin from over-stretching. The chest 
is protruded and is convex. The back is sharply incurved to re- 
ceive the occiput, while the breech is turned to the back. The fetus 
is lengthened, while its axis takes the shape of the letter S. 



NOTES ON OBSTETRICS— JUNIOR CLASS. 179 

Diag}iosis. Meiito-Dc.vtra Posterior Position. 

Abdominally. Longitudinal ovoid. Head over the inlet. 
Breech and small parts in the fundus. Hard to feel the back. On 
one side of the inlet can feel a large, hard prominence and above this 
a deep furrow. On the other side, hard to feel anything. Some- 
times possible to make out a horse-shoe shaped jaw. 

The feet are on the same side as the breast, i. e., the right side ; 
the heart tones also on the right side, since the breast is applied 
to the uterine wall. Important finding, that the extremities and heart 
tones are on the same side. Three points of face presentation are : 
1st. Large, round occiput on one side, with a deep furrow above it. 
2nd. No tumor on other side or possibly can outline the jaw\ 3rd. 
Extremities and heart tones on the same side. Heart tones very loud 
because so near the ear. In these cases may feel fetal heart. 

Vaginally. Early in labor, the pelvis empty. Bag of waters not 
round, but irregular, and persists between pains. High up even in 
primiparae, an irregular, square body, generally movable. If the 
bag of waters ruptures, there is generally no difficulty in recognizing 
eyes, orbit, nose, mouth. The chin is usually out of reach, as is also 
the large fontanelle, unless it be a brow presentation, or a face, in the 
process of transition. No hard, rounded tumor but one with prom- 
inences and depressions. Occasionally find a face presentation at the 
beginning of labor which changes to occiput. 

The most important diagnostic point is the saddle of the nose. 
This can be recognized even if the face be swollen by the disfigur- 
ing caput succedaneum. 

The mouth and nose are in the "facial line," also the chin. The 
facial line in M. D. P. lies in the ist oblique diameter of the pelvis. 
Chin is the point of direction. 

After the head has come down, the face is more easily reached, 
and then usually the whole of its outline, including the chin, can be 
palpated. Difficulty arises now because the face may be so swollen 
and disfigured that the parts are hard to outline. The root of the 
nose wnll help out here. The finger in the mouth feels 2 gums and 
the tongue (which sucks if the child is alive). The most common 
mistake is to think the face is a breech. In Mento-Laeva Anterior, 
diagnosis is the same but points are transposed from left to right. 

Mechanism of Labor in Face Presentation. 

The face is usually high up at the beginning of labor. The first 
movement is extension, not flexion. If the case was one of primary 
face presentation very little extension is necessary to complete the 
movement, but if one of the secondary forms, the forehead or brow 
presents, and it requires that resistance be met to form the com- 
plete face presentation. These transition forms can be often diag- 



180 NOTES ON OBSTETRICS— JUNIOR CLASS. 

nosed if patient is examined early enough. The brow end of the 
lever is longer ; therefore, the chin goes down, the brow being held 
back. 

The second movement is descent. This is due to the same causes 
as in vertex presentation. G. L U. P., F. A. P. and gravity to a 
less extent. Flexion and descent occur at the same time in vertex 
presentation, extension and descent in face presentation. 

The third movement is anterior rotation. The chin is the point 
of direction and rotates anteriorly. Mechanism is the same as in ver- 
tex. The rotation is brought about by the rotation of the trunk 
to the front, and the anterior inclined plane of the pelvis. Some- 
times face has to come deep on the pelvic floor before rotating. 

Anterior rotation must start early because the head cannot enter 
the pelvis with the chin entered behind. This would bring the occi- 
put and the chest into the inlet at the same time, which is possible 
only under exceptional circumstances, i. e., small and soft child, 
large pelvis, strong pains. 

The labor is harder, slower. The pains must be stronger to 
effect rotation. The soft face pressing against the lower uterine 
segment does not evoke such strong contractions as the hard vertex. 
The face seems to be farther in the pelvis than it really is. One 
believes the head engaged when the bi -parietal diameter really is 
still above the inlet. This is due to the greater length of the lower 
part of the head. 

In vertex presentation the greatest periphery of the head is about 
3 cm. above the point the finger touches. In face, the greatest 
periphery is 7 cm. above the point the finger touches. Therefore, be 
careful in saying whether the head is engaged or not. 

Remember, also, that anterior rotation may not occur till the 
head is well down on the perineum. The chin always turns into the 
transverse diameter at least before reaching here. Face descends, 
chin selects the diagonal and the rotation completing, the chin ap- 
pears at the vulva. Perineum bulges less than wath the vertex, mouth 
appears first, then the chin, the neck stems behind the pubis and the 
nose, forehead, large fontanelle, and vertex sweep over the perineum. 

The 4th movement is one of flexion, not extension ; the chin 
flexes toward the sternum and rides on top of the symphysis. 

The fifth movement is external restitution, i. e., the chin rotates 
to that side which it had in the uterus. The delivery of the trunk 
is similar to that in vertex presentation. ^ 

In all face presentations it is highly important that the chin comes 
anteriorly. Unless this occurs, labor is seldom possible. 

The same anomalous mechanisms can take place with the face as 
occur with occiput presentations. 

1st. Deep transverse arrest of the chin. Face comes down well 
on the perineum, but anterior rotation does not occur. Under very 



NOTES ON OBSTETRICS— JUNIOR CLASS. 181 

favorable conditions, /. c, strong pains, small child, large and soft 
vulva, child may be delivered in this position, but may not, and 
if aid is not rendered both may die. 

2nd anomaly. Chin may remain at the right sacro-iliac joint 
or rotate posteriorly, and we have a condition analogous to posterior 
rotation of the occiput. 

These cases are pathological and very dangerous for both mother 
and child. But still nature may terminate them in one of several 
ways : 

1. Rotation of the chin through an arc of i6o degrees, and then 
chin under pubis, normal termination. 

2. The brow may stem behind the pubis, the chin and mouth 
then come over the perineum ; neck on the perineum forms the cen- 
ter, the forehead, vertex, and small fontanelle rotate from under 
the symphysis. 

All these are pathological, and only in exceptional cases to be 
relied on. Child very often dead and mother exposed to the dangers 
of ruptura uteri and ruptured perineum. 

Clinical Course. 

In face presentation the labors are usually more tedious, the 
pains are not so strong. The face does not engage till late though 
it is low, but must be well down on the perineum before the bi- 
parietal diameter can pass the inlet. 

Labor is longer in the first as well as in the second stage. Ef- 
facement and dilatation of the cervix are slow^er. Bag of waters 
likely to rupture earlier. 

In primiparae the length of the labor is 3 to 4 hours longer 
than with occipital presentation ; in multiparae, i to 2 hours. But 
sometimes the labor lasts many hours, may be days, in both, while 
it may proceed rapidly, ending in a few hours. The cause of the 
face presentation has something to do wdth it, e. g., contracted pelvis, 
large child. But with all this, face presentation must be considered 
as Eutocia, though it may easily become pathological. In almost all 
cases patient is able to terminate labor herself. Formerly all cases 
were operated on at sight, but this is bad practice. 

Prognosis. 

For the Mother. Mortality higher than the vertex presentation, 
due to longer labor, greater danger of infection (not so much nowa- 
days), vesico- vaginal fistula, and the necessary operations (also the 
unnecessary ones). 

Boer had 90 face presentations, one forceps, 4 dead children, and 
his work served to change the tendency to operate in all face cases. 

For the Child. Mortality is higher because the labor is longer. 



182 NOTES ON OBSTETRICS— JUNIOR CLASS. 

especially the second stage ; the pressure of the neck against the 
symphysis may cause cerebral hemorrhage or injure the trachea, 
both seldom. Mortality is twice that of vertex presentation, i. e.. 

Plastic Changes. 

Face is horribly disfigured, especially if the labor has been long 
after the rupture of the bag of waters. 

Caput succedaneum forms on the cheek and eye, later over the 
whole face. Eyes bulge out and ecchymotic, lids swollen, face 
swollen, blue, and small hemorrhages, lips sometimes so swollen that 
the baby cannot nurse for some days. May be a muco-serous dis- 
charge from the eyes in severe cases. Ophthalmia neonatorum. 
Scratches from the examining finger on the face and eyes. Head 
flattened out, top of head may even show a saddle-like depression at 
region of the large fontanelle. Occiput long drawn out, head being 
dolico-cephalic. 

Child keeps the extended attitude for one to four days. If it was 
a primary face, longer, if a secondary, not so long. The changes 
of the face disappear in a few hours to 5 days, depending on the 
degree and this depends on the length of labor. Reassure the 
mother that the child will again look like a baby. 

Treatment. 

Face presentations are normal, therefore no other than that of 
vertex presentation, unless something happens to indicate operation. 

Higher Degree of Expectancy. During the examination be care- 
ful not to rupture the bag of waters. Be careful not to scratch the 
eyes or face, and especially not to infect the eyes with the vaginal 
secretions. It the head is found in a transition from vertex to face 
put the woman on the side to which the occiput points. If the face 
presentation is formed, put her on the side to favor descent and 
rotation of the chin, i. e., that side to which the chin points. 

In the first stage, do nothing except to build up patient's strength. 
In the second stage. Expectancy, arbitrary limit is 7 hours. Do 
nothing except under the strictest indication, since the operations 
are harder and worse for the mother and child. Can wait 7 hours, 
because the soft face is not so likely to cause fistulae as the hard 
head. Watch uterus carefully. Difficult to protect the perineum, 
since one cannot press on the face. Still, may try to get the best 
diameters through the vulva. In primiparae, perform episiotomy. 
Some authors advise transformation of face to a vertex presentation, 
others advise to turn the child around and bring the feet down. 
The latter operation must be reserved for special indications. Under 
special conditions we change a face presentation into vertex, such as 



NOTES ON OBSTETRICS— JUNIOR CLASS. 183 

chin posterior position. Operations can only be done before en- 
gagement has taken place, or it causes serious injury to the pas- 
sages. If done when the head is high up, face position may recur. 
In general, it is better to pursue a purely expectant plan of treat- 
ment with face presentation. See senior notes. 

B roii,' Presentatio n . 

One may find, in the first stage of labor, the head over the 
inlet in such a stage of deflexion that the brow is first touched by 
the examining finger. This condition seldom persists. Almost al- 
ways either flexion or extension of the chin occurs and we have 
from the first an ordinary occipital presentation ; from the second, 
a face presentation. Latter more frequent, and if you can feel the 
root of the nose, almost certain it will be a face. Still, should the 
head enter the pelvis in the middle position, it can hardly change 
now, and passes through the pelvis in a brow presentation. The pos- 
ture is pathological, and very often requires aid. The point of direc- 
tion being the brow, we have the same names as in the others, /. e.: 
Fronto Laeva Anterior. 

Fronto Dextra Posterior. Only two occur in nature. 

Causes are the same as for face presentation. Principally, the 
causes which make a deflexion of the chin. The attitude of the 
fetus is similar to that of the face presentation. 

The diagnosis is nearly the same. The continuation of the facial 
line, the frontal suture, is used in determining the position of the 
head. The root of the nose on one end and a large fontanelle on 
the other. Thus, in fronto laeva anterior, one feels the large 
fontanelle to left side. The root of the nose to the right. The 
frontal suture usually runs in the transverse diameter. 

In the right fronto-posterior, the large fontanelle is to the right, 
the root of the nose left. Can feel the point of the large fontanelle. 
Other points in the diagnosis are the same as in the face presenta- 
tion. 

Mechanism. 

(i) Descent: (2) extension or flexion is not marked, head 
comes down in the middle position. Frontal suture generally takes 
the transverse diameter. Now the brow rotates to the front, the 
occiput rotates to the sacrum. INIechanism complex. The brow ap- 
pears, then the eyes, the chin extended behind the pubis, and then 
the whole vertex rolls over the perineum. Now the chin comes from 
behind the pubis. Whole, mechanism is slower, harder and dan- 
gerous to mother and child. Great danger to the perineum be- 
cause the largest cranial diameters are opposed to the outlet. If 
the child is large, operation almost always necessary. It is said 



184 NOTES ON OBSTETRICS— JUNIOR CLASS. 

that brow cases are small, babies, thus labor can sometimes end spon- 
taneously. 

Prognosis. 

Bad. Fifty per cent, of the children are still-born, according to 
Hecker. Ahlfeld has had a low mortality rate. For the mother, 
prognosis is worse than face presentation. 

Plastic Changes. Head is flattened out between the 
chin and large fontanelle. Distance from chin to top 
of forehead is very great. Head presents a character- 
istic three-cornered outline. Forehead is high, face fiat 
and the line from the forehead to the occiput is steep. 

The caput succedaneum situated on top, increases the length of 
the brow. The occiput is pressed into the nape of the neck. 

Treatment. 

If the case is one of transitory brow^ presentation, expectancy. 
Should the head remain fixed in this posture, justifiable to change 
it to a vertex presentation, to a face, or to do a version by the feet. 

After head well engaged one may flex the head, producing an 
occipital presentation, or complete deflexion, making a face presenta- 
tion, but the maneuver may only be done by skillful hand, as it may 
cause grave injury to the maternal tissues. Forceps, if there is an 
mdication besides the mal-position. 

BREECH PRESENTATION. 

The child presents itself for labor with the breech in advance in 
2 7/10% of the qases. In general terms, 3%. There are several 
varieties of breech presentation : 

1. The complete breech, in which the buttocks with the feet 
alongside present at the os, or are bounded by the girdle of resist- 
ance. 

2. Incomplete breech presentation where, 

(a) One foot has (or maybe 2) fallen down into the vagina, 

footling presentation. 

(b) One knee has fallen down into the vagina — knee presen- 

tation, or both knees, 

(c) Where the feet are turned up against the face, the legs 

being extended at the knees, the two limbs being laid 
on the front of the body like a splint, sometimes called 
''single" breech presentation. By the French ''mode 
de fesses." 
The labors in all run about the same. Therefore we will not con- 
sider each separately, but take them altogether, using the complete or 
"double" breech (as it is sometimes called) for the example. 



NOTES ON OBSTETRICS— JUNIOR CLASS. 185 

Causes of Breech Presentation. 

Not certainly known, since the baby may present no causes, nor 
the mother. Still breech cases often occur in the following condi- 
tion : 

1. Maternal. 

(a) Anything that will prevent the engagement of the head; 

e. g., contracted pelvis, tumors in the pelvis, placenta 
previa. 

(b) Hydramnion (free to move around). 

(c) Multiparity. 

2. Fetal. 

(a) If the head is too large to get into the pelvis, e. g., hydro- 

cephalus. It is usual for the hydrocephalus to come 
last. Some tumor of the neck or head, e. g., goitre, 
Lymph-angioma. 

(b) Small fetuses and large amount of liquor amnii, there- 

fore in premature births breech presentation is com- 
mon ; in twin pregnancy one child likely to be a breech. 
Said that scrub women have breech presentation fre- 
quently from the position assumed by them ( ?). Often 
no cause discoverable. 
Positions of the fetus in utero. 

There are four positions, but in nature only two are commonly 
observed. The child may lie with its back to the right or to the left 
and it may be directed more anteriorly or more toward the back of 
the mother. The sacrum is the point of direction. The posture of 
the fetus is the same as in the vertex, but is inverted. 

Findings in Skier o Laeva Anterior. 

Complete Breech. More common attitude. 

Abdominally. Longitudinal ovoid. Over the inlet one usually 
feels nothing, or the breech. Right, at fundus, the head. Shoulder 
above navel, median or a little to the right. Back to the left. Heart 
tones to the left, in front, i^ to 2 inches above the trans-umbilical 
line. Head usually near liver. 

Vaginally. Usually the breech is high up. Even in primiparae 
It does not engage till late. Bag of waters often ruptures early, since 
the lower uterine segment is not applied to the presenting part. Feel 
a soft body that is not the head, irregular outline, but can generally 
make out two soft prominences, deep depression between them ; to 
each side may feel tuberosities of the ischia. The anus may be felt, 
contracts on the finger, and you may find some meconium on the fin- 
ger. Between the two tuberosities of the ischia can feel a crease, the 
genital crease. Following this up (in S. L. A.), feel the scrotum or 
vulva behind, to the right. Anterior and in front can feel a triangu- 



186 NOTES ON OBSTETRICS— JUNIOR CLASS. 

lar bone with three or four prominences on it — the sacrum. This is 
the point of direction and the quadrant of the pelvis in which it Hes 
gives the position. The anterior buttocks is more easily outlined. 
Alongside the buttocks of the child toward the right side (in S. L. 
A.) you can feel the feet. Usually one is felt, sometimes two. Ob- 
serve care in diagnosis. Mistakes common, e. g., with face, bag of 
waters, etc. 

If it is a footling presentation, the foot which is down, will help 

* the diagnosis. Diagnose foot by direction of big toe and the flexure 

^ of the knee, by following it up part way into the vagina. Can see if 

it is the anterior or posterior foot. This point settled, it is to decide 

the position of the breech in the pelvis. A foot may prolapse with a 

vertex presentation. ^ 

In Single Breech, w4ien the feet are extended along the chest and 
face, it may be possible to feel the feet alongside the head, through 
the abdomen. Otherwise the abdominal findings are the same as in 
other forms. The uterus is longer and straighter. It is arched in 
the other breech presentations. Vaginally, one feels the nates only 
and determines the points as before given. Do not pass the finger 
too far into the anus, because it may excite respiration. The advice 
is usually given, but the author has seen no case where such an acci- 
dent occurred. 

Mechanism of Breech Presentation. 

Must consider mechanism of the breech, shoulders and the head. 
Sacra Laeva Anterior. Movements of the breech. 

Breech almost always remains high up, even in primiparae, till 
labor is well advanced. The movements of the breech are of the 
least importance, those of the head and shoulders being most impor- 
tant. 

ist Movement. Descent. Slow, due to same causes as in occi- 
pital presentation and occurs at same time. 

2d Movement. Flexion. Body flexes toward the side to adapt 
its axis to the axis of the inlet. 

jrd Movement. The breech comes down with the bisiliac diam- 
eter in the left oblique, the genital fissure in the right oblique. 

The anterior hip points to the right ilio-pubic tubercle, the ante- 
rior buttock is a little lower than the posterior, the obliquity of Na- 
gele. 

The breech has descended to the floor of the pelvis, but the feet 
are usually held back a little. Now anterior isolation takes place, 
i. e., the anterior hip rotates to the front and comes under the sym- 
physis, bis-iliac diameter now antero-posterior, the genital fissure 
in the transverse diameter. 

4th Movement. The anterior hip becomes visible in the vulva and 
stems behind the pubis, the posterior hip rolls over the perineum. 



XOTES ON OBSTETRICS-JUNIOR CLASS. 187 

The whole pelvis rises up toward the pubis. This is especially 
marked in cases where the perineum is well preserved. 

jth Movenieuf. External restitution. Breech rotates so as to 
iDring the back to the front, may even rotate to the other side. This 
is called external over-rotation, and may occur wath the head also. 
It has happened with the breech as well as the head that the internal 
anterior rotation was excessive, the point of direction passing the 
median line over into the opposite anterior quadrant of the pelvis. 
This is called internal over-rotation. Causes not known, but a large 
pelvis required. One can draw no positive inference of the position of 
the head and shoulders from the position of the breech. After the 
shoulders are delivered can tell the position of the head. 

Movements of the shoulders are the same as those of the breech. 
Descent occurs with the bis-acromial diameter in the left oblique. 
The arms lie folded across the chest. More muscular exertion is 
needed to force the shoulders down. The anterior shoulder lies 
near the right ilio-pubic tubercle and rotates to the front. Now the 
shoulder stems behind the pubis, and the posterior shoulder is deliv- 
ered first, over the permeum. Then comes the anterior shoulder. 
The back now rotates to the front. The nape of the neck resting 
imder the pubis. 

Mechanism of the Head. 

Is the same as in occipital presentation. AMien the shoulders are 
at the vulvar orifice the head begins to enter the pelvic inlet. The 
head is well flexed on the sternum. The same diameters are opposed 
to the girdle of resistance, but they are in an inverse order. The 
head presents the shape of a double wedge ; in vertex presentation 
the obtuse angle A goes in advance. In breech presentation the 
acute angle B goes in advance, therefore the head will go through 
the pelvis easier in breech presentation than in head presentation, 
which is in accordance with the fact. 



Movements are (i) descent; (2) flexion: anterior-posterior diam- 
eter of the head enters pelvis in right oblique, as in occipital presen- 
tation; (3) anterior rotation occurs as a result of the ordinary mech- 
anism. The occiput com^s to the pubis, the chin rotates to the sac- 
rum. Now flexion (4)^ takes place, the nape of the neck being the 
center and the chin, face and forehead come over the perineum, then 
the occiput comes from behind the pubis. There is no external resti- 



188 NOTES ON OBSTETRICS— JUNIOR CLASS. 

tution. Mechanism in right sacro-posterior the same, but with a 
change of the terms. In posterior breech cases the back often rotates 
across the pelvis in front of the promontory of the sacrum to the 
opposite side, traversing three-fourths of a circle, before delivery. 

Plastic Changes. 

The caput succedaneum is found on the anterior hip. In the 
case of S. L. A on the left. But the swelling may extend over both 
hips, and the genitals, which especially in the male are likely, if the 
labor be long, to be swollen, the scrotum becoming blue and edema- 
tous. In girls there may be a slight leucorrhea the first few days. 
The head is not moulded ordinarily. Owing to its rapid transit 
through the pelvis it is not changed in shape, but preserves the round 
shape it had in utero. More true of multiparae. If the labor is very 
long, especially if the bag of waters rupture early, the child stayed a 
long while in the dry uterus, from the continued pressure on the top 
of the head by the fundus uteri, this is likely to be flattened and the 
child be a little dolico-cephalic. This was especially pointed out by 
Fritsch. Also the head may be asymmetrical owing to the pressure of 
the uterine wall against its anterior surface. This sometimes persists 
for years. A shortening of the opposite sterno-cleido mastoid mus- 
cle has been observed. (DeLee.) 

The Clinical Course of Breech Labors. 

During pregnancy breech presentations sometimes cause symp- 
toms that attract attention. Women often complain of pain and dis- 
tress in the epigastrium, due to the pressure of the head, and this is 
relieved if the fetus changes position. Lightening does not occur. 
If there is oligo-hydramnion there may be a congenital shortening 
of the neck muscles of one side, owing to the cramped position of 
the head. One of the causes of wry-neck. 

Breech labors on the average are shorter than the head labors,, 
but this is due to fact that many are premature births and small 
children. 

Reckoning only full term children, the labors are a little longer 
than the cephalic cases. This is especially true of primiparae. 

The breech remains high in both till the cervix is well dilated, 
then it comes down. The bag of waters ruptures early more often 
than in head cases. If so, the efifacement and dilatation are slower. 
In multiparae the breech comes down rapidly, rotates to the front and 
is delivered, the shoulders quickly follow, the arms being at the side 
of the chest. A few pains, or one long pressing pain by the abdom- 
inal muscles, and head is expelled. 

In primiparae, the w^hole mechanism is longer," more pains are 
necessary to expel the child. Sometimes in spite of good, strong 



NOTES ON OBSTETRICS— JUNIOR CLASS. 189 

pains the breech does not move for hours. Finally the breech comes 
down and the shoulders are delivered ; the head is more likely to be 
arrested, owing to the tight cervix and perineum. Both are also in 
more danger of being torn. 

During the labor, meconium may escape freely. This is especi- 
ally true while the breech is coming over the perineum. Has no 
significance, being due simply to the pressure of the uterus on the 
body of the child, the region of the anus being under less pressure ; 
therefore the same causes as those of the caput succedaneum. If 
meconium escapes before breech is engaged it has the same signifi- 
cance as in head cases. 

In cases where the breech is complete, the delivery of the shoul- 
ders and head is more easily accomplished, since the cervix and peri- 
neum are more completely dilated. If the small body goes before, 
the cervix is poorly prepared for the large head. This is an impor- 
tant point in the treatment because if the cervix is not well dilated 
it may close on the neck of the child and imprison the head in .the 
uterus. See Senior Notes. 

Prognosis. 

For the mother the general prognosis is very good, still it is not 
so good as in occipital presentation. 

I. Labor is longer. The mechanism of effacement and dilatation 
of the cervix is not so complete. But the labor is easier than in head 
presentation. 

II. Lacerations of the cervix are much more common, likewise 
lacerations of the perineum. Complete tears into the rectum are most 
often found with breech presentation, due to the rapid passage of 
the head through the vulva, but they are mostly errors of art. 

III. Disturbances in the mechanism of labor are very likely to 
occur. The arms may be displaced upward, over the head or into 
the neck, the head may rotate in a wrong direction ; all these cloud 
the prognosis for the mother. 

If none of these accidents happens, if the patient is in the hands 
of a clean and careful accoucheur, the prognosis is good as far as the 
mother is concerned. Breech presentation is Eutocia and should not 
be interfered with. 

For the fetus the prognosis is less good. Mortality is over io%, 
often 13% or 14%, but with the best treatment the mortality should 
not be over 5%, if as high. 

The child is in danger of asphyxia after the breech is born. 

1st. From compression of the cord between the soft parts and 
the fetus. When the breech appears the navel is just passing the 
external os, and now^ the danger begins. This is not so important 
as the 

2nd. Premature detachment of the placenta. When the head is 



190 NOTES ON OBSTETRICS— JUNIOR CLASS. 

expelled in head presentation the placenta is generally separated 
wholly or in part, but the child can get air. 

In breech presentation, after part of the body is delivered, the 
placenta begins to separate, but the fetus is not ready to begin 
extra-uterine respiration yet. If it starts to breathe, it sucks in 
liquor amnii and blood. 

3rd. Even if the placenta remains in place, it mav be so C07n- 
pressed by the hard head that there is interruption of the circulation 
in the placenta, therefore too early inspiration. In vertex presenta- 
tion the soft breech presses against the placenta. 

4th. The exposure of the body of the child to cold rnay also in- 
cite too early respirations. 

A child will live after the breech is born before complete expul- 
sion, from 5 to 10 minutes. Exceptionally after 10 minutes, and 
there are cases on record where a child survived 15 minutes or more 
after the breech was born. Not to be expected. It is the same time 
that a child will live in the uterus after the sudden death of its 
mother. The delay in delivery due to anomalies in the attitude or 
in the mechanism may cause asphyxia. The arms may strip up 
above the head, the neck may be tightly grasped by the cervix. 

Finally, injuries to the child are more common in breech presen- 
tation, especially during extraction. 

Breech presentation is Eutocia for the child also. 

In old primiparae, where the vulva and vagina are tense and 
rigid, there is much more trouble in extracting the breech, and the 
danger of maternal injury and fetal asphyxia is much greater. In 
them breech presentation is sometimes Dystocia. 

Treatment. 

Watchful expectancy, as long as there is no danger to the mother 
or fetus. Be careful not to rupture the bag of waters. Woman may 
walk round a little, resting often. 

Remember that the first stage is longer, especially in primiparae. 

When the cervix is dilated and the second stage begun, place the 
patient across the bed in the lithotomy position or on a table, which 
is better. Do not use an anesthetic, unless some operation is neces- 
sary, or the patient is unruly, because you want the patient to bear 
down and express the child herself. Have everything ready for treat- 
mg asphyxia of the new-born child, i. e., warm towels, hot bath, tra- 
cheal catheter. Sit by with sterile hands, and watch the breech ap- 
pear, doing nothing unless it comes too slowly. Wrap a warm sterile 
towel around the breech as it appears. If the foot comes, do not in- 
terfere with it. 

When the navel appears tell the woman to bear down. She must 
expel the child quickly. If she does not, or is anesthetized, have an 
assistant press down on the fundus with his full hand. This presses 



NOTES OX OBSTETRICS— JUNIOR CLASS. 191 

the fundus against the head and eHcits strong pains, and also helps 
expel the child. 

By extraction we mean the operative delivery when a foot pre- 
sents, or when the w^hole of the fetus is in the parturient canal. 

By manual aid we mean the assistance rendered after the natural 
powers have delivered the fetus to the shoulders, and we aid the 
birth of arms and head. 

Differentiate these well. 

The indication for finishing the labor is asphyxia, and the signs 
are : 

.1. Slow pulsation in the cord, which can be felt running from the 
navel up into the uterus. 

2. Inspiratory movements can be seen or felt. 

3. The passage of meconium has very little significance here, but 
a great deal in cephalic presentation ; unless the breech is still not 
engaged. 

Manual Aid. 

Have an assistant press down well on the fundus. Grasp the 
breech of the fetus in both hands, thumbs over the sacrum, index 
fingers on the crests of the ilia, other three fingers on the upper part 
of the thigh. I\Iake traction in the line of the inlet, i. e., downward,, 
gently, steadily. When the anterior scapula is palpable or visible 
under the pubis it is time to deliver the shoulders and arms. 

Deliver the posterior arm first. 

Grasp the feet wdth the hand and pull them to the groin in the 
direction of the abdomen of the baby, this pulls the shoulder down 
and helps to rotate it into the hollow of the sacruirt, where there is 
more room for the necessary manipulations. Here pass two fingers 
over the back and shoulders of the fetus {leave the thumb outside), 
down the humerus to the elbow. Now pull on the elbow so as to 
bring it down over the chest of the fetus, so that the infant's hand 
wdpes across the face. Do not press on the humerus, because you 
might break it. Always press on the elbow and do not pull 
the shoulder dow^n so as to bring it into reach, since fractures of the 
clavicle almost alv/ays result ; pass the fingers high up ; if tw^o not 
enough, take four. Leave the thumb outside ahvays. 

After this arm is disengaged let the baby fall into the two hands, 
place the delivered arm against the chest as a splint, and gently 
turn the baby so as to bring the other arm behind nearly into the 
hollow of the sacrum. Now take the feet of the baby in the hand 
as before, pull them toward the groin of the opposite side, and extract 
the second arm in the same manner as before. 

Let the baby fall into the hand that brought down the second 
arm so that the baby rides on it, one foot on each side of the fore- 
arm, put the index finger into the mouth, or two fingers, and flex 



192 NOTES ON OBSTETRICS— JUNIOR CLASS. 

the head on the sternum ; usually find the mouth off to one side. If 
so, can easily bring it behind and to the median line. Now put the 
fingers of the other hand over the neck fork-like, well down on the 
sternum (to save the clavicles), and make gentlest traction down- 
ward till the nape of the neck is well under the symphysis. Have 
the assistant press down from above to make the minimum amount 
of traction below necessary. Now stand off to one side so as to see 
the perineum, and bring the chin out over the perineum, letting the 
nape of the neck rest under the pubis, face, forehead and occiput 
appear by flexing the head over the pubis. If any trouble experi- 
enced, do the Martin- Wiegand method. 

If (after the breech is delivered) the cord be too tight so that you 
cannot pull down a loop, cut it. If the cord is between the legs over 
the buttocks, slip it up, if too tight cut it and hurry. 

Have an assistant -exerting constant pressure over the fundus 
with both hands. Idea is to prevent arms from sliding alongside 
the head and to prevent deflexion, also to make too much traction 
below unnecessary. 

After the shoulders are delivered the harder part of the operation 
is completed. Usually the fetus is in little danger and there is time 
to do episiotomy if it is deemed necessary. Still if you are going to 
do episiotomy do it before the breech comes out. It is generally 
done in primiparae. 

The method described is known as the Snullie Veit method. 
Sometimes called the Mauriceau-La Chapelle method. There are 
very many methods for these cases, but this is now most generally 
practiced and is almost always successful. In abnormal cases it is 
very successful, but in normal cases it is usually not necessary, na- 
ture ending the labor herself. The Martin-Wiegand method is also 
a good one. 

Treatment, Then, of Breech Presentation Is: 

1. Watchful expectancy (unless some indication) till breech is 
born to navel. 

2. Tell the woman to bear down. 

3. Assistant makes pressure on uterus. 

4. Manual aid, of which there are three stages or acts : 

1 . Delivery to the shoulders ; 

2. Delivery of the arms ; 

3. Delivery of the head. 

Treatment of footling presentation is the same. Do not pull on 
the foot. Replace it in the vagina and if this does not succeed, 
wrap it in a sterilized warm towel. 

Umisual Mechanism of Breech Presentation. 
I. The back may rotate to the back of the mother and the belly 
to the symphysis. 



NOTES ON OBSTETRICS— JUNIOR CLASS. 193 

Terminations (a) may finally rotate to the front; (b) may be 
delivered iii this way : 

2. Arms may be drawn up over the head, or into the neck. 

3. The head may come with the occiput directed to the sacrum, 
the chin to the symphysis. 

Terminations : 

a. Chin flexes, head delivered with the occiput behind; 

b. Chin extends over pubis, occiput comes over perineum, 

child being lifted up ; face comes out last ; 

c. Rotation finally takes place, or is produced by the ac- 

coucheur. 
All are pathological and will be considered next year. 

TWIXS. 

The occurrence, causes and diagnosis of twins were already dis- 
cussed, under "Pregnancy." 

The same remarks apply to the diagnosis of twins during labor 
as during pregnancy. 

Attitude of the Fetuses. 

I\Iany positions possible. Most common is both fetuses present 
by the head, 53% ; next, one head, one breech, 29% ; both by the 
breech in 9% ; one transverse and other longitudinal, and finally, 
both transverse (most rare). 

When the presentation is longitudinal the children lie in utero 
with the bellies apposed, the backs to either side. One is usually a 
little lower than the other, and this one usually engages first, though 
it may not. 

There is almost always a fold of membrane between the fetuses, 
which more often has four layers, two amnions and two chorions. 
When the fetuses come' from one ovum there are only two layers 
(amnions),- and it has happened that this has atrophied, and the two 
children wefe free in one amniotic cavity. In these cases the cords 
can become twisted around each other and parts of the bodies. \^ery 
rare occurrence. 

The Clinical Course of Labor. 

Labor, especially the first stage, is usually very slow. The great 
distension of the uterus prevents it from contracting strongly. 
Therefore effacement and dilatation of the cervix are slower. Ow- 
ing to the great abdominal distension, edema of the feet, dyspnea, 
albuminuria and eclampsia are more common. 

The mechanism of the expulsion of the first child does not differ 
from the normal, be it a head or breech presentation. Still twin 
births are very likely to have irregularities, and becom.e dystocia. 



194 NOTES ON OBSTETRICS— JUNIOR CLASS. 

After the expulsion of the first child there is a pause. This may 
be from lo to 60 minutes. Exceptionally several hours, and in very 
rare cases days may intervene, before the birth of the second child. 
During this pause there is generally a small amount of blood lost. 
It sometimes happens that the placenta of this child is now delivered ; 
pathologically, the placenta of the second child may be delivered. 

If the second twin comes spontaneously the delivery is very 
rapid, since the pains are now stronger (the fibres of the uterus hav- 
ing gotten somewhat shorter), and the parts have been dilated by 
the first so that little resistance is met by the second child. 

After this child is born there is a great tendency to hemorrhage 
because of uterine inertia. The great distension of the uterus has 
diminished its contractibility and retractibility. Anomalies in labor 
are likely to occur. 

1. Pathological presentations. 

Shoulder presentation or face and brow presentation. These 
occur in a goodly percent of the cases. 

2. Different presenting parts are found over the inlet. Fmally, 
one part will descend and become engaged. 

3. It may happen that the bag of waters of the second child 
ruptures before that of the first, or the two together. Usually no 
trouble. The second child is delivered more quickly after first is 
born. 

4. In cases w^here one fetus presents by the breech, and the other 
by the head, the first may be half delivered when the second comes 
down, the head enters the pelvis alongside the chest of the first, and 
"locking" or "collision" occurs, the face of one child is pressed 
against the neck of the other. Occurs i in qcocx) cases. In rare 
cases nature terminates the labor. The head and body of the second 
child are forced out, then the head of the first is delivered. Thus 
w^e take the hint from nature. Deliver the second child first, by 
forceps, or cranioclasis, then the first child. It may be better to 
decapitate the first and then deliver the second twin. 

When both present by the head the occiput of the second child 
may get in between the chest of the first and the sacrum and stop 
labor, by "locking," or "collision" by the cephalic extremities of the 
fetal poles. 

5. The placenta of the first child is delivered before the second is 
born. Rarely the placenta is completely separated from the second. 
If the two are joined and the placenta is delivered, only the rapid 
delivery of the second child can save it. The accident is rare, but if 
partial separation of the placenta should occur, the mother is men- 
aced by dangerous hemorrhage and the fetus with asphyxia, there- 
fore control the heart tones of the second child. 

6. It sometimes happens that the passage of the first twin alters 
the position of the second : sometimes from a longitudinal position 



NOTES ON OBSTETRICS— JUNIOR CLASS. 195 

to one transverse or an anterior position to a posterior position of 
the occiput. Ahlfeld saw this occurrence eight times in 44 twin 
laboj-^.. The arm or cord may prolapse. 

Prognosis. 

For the mother prognosis is good. Twin labors are in the limits 
of Eutocia, but are near the border Hne ; 82% of the positions are 
longitudinal and as a rule the mother completes the labor spontane- 
ously. Still the prognosis is not so good as in single pregnancies, 
since, 

1. During pregnancy the greater size of the uterus and the 
greater intra-abdominal tension cause albuminuria, edema and some- 
tmies eclampsia. In a given case, absence of albuminuria may shut 
cut twins. Tendency to nephritis is more marked. 

2. Labors are longer. Uterus cannot act well on the two bodies 
at once, and, further, the uterine muscle is so stretched that it cannot 
act strongly. Danger of infection is greater and then the various 
operations which are made necessary by the atony uteri or the mal- 
presentations also increase the morbidity and mortality. 

3. The patient is liable to hemorrhage between the two births 
and especially after the third stage is over. This is from atony of 
the uterus, so-called uterine inertia. This increases the liability to 
infection during the puerperium. 

4. For the child, prognosis is not good. The majority of twin 
births occur a few weeks before term, a large percent over four 
weeks. A large percent dies in the first days after labor, 20% in 
the first 10 days. A high percent is still-born. It is estimated that 
75% die in the first year of life. I think this is too high. This is 
due to the facts that first, they are often premature ; second, the 
mother, weakened by the double pregnancy, may not have enough 
milk for two infants. 

Treatment. 

The same as in ordinary labor, "watchful expectancy." It may 
take a day or two (rare) for the cervix to dilate fully; patient has 
sometim.es false pains for weeks before labor. Wait and do not 
rupture the bag of w^aters unless there is some indication. 

After the first baby is born, you must watch carefully for two 
things : 

I. Hemorrhage from the mother, external and internal. 

II. Asphyxia of the child. 

Stand ready to deliver the second child, and if either occurs, 
have somebody control the heart tones constantly. If they are nor- 
mal and no hemorrhage, wait. The uterus gathers strength and 
after 10 to 60 minutes a new bag of w^aters forms. It usually rup- 
tures early, if not it is justifiable to rupture it after 30 minutes. If 



196 NOTES ON OBSTETRICS— JUNIOR CLASS. 

there is hemorrhage or if asphyxia, must rupture the membranes and 
extract at once. 

The dehvery of the second child is rapid, and after this carefully 
guard the uterus. Tie the cord of the first child in two places so 
that the second child does not bleed from it. The placentae generally 
communicate. 

Regarding the delivery of the first child, the ordinary rules hold, 
likewise of the second. If the latter has been turned into a bad 
position by the first child in passing, this must be rectified. Pro- 
lapses of the cord and extremities are not uncommon with the sec- 
ond child, but since all the conditions are present for rapid delivery 
there is seldom any danger to the child, if the attendant is watchful 
and prepared for emergencies. 

The third stage requires great attention. jNIassage the uterus 
gently right after the children are born. Have ergot and hot vaginal 
douche ready. If bleeding occurs get the uterus hard by massage 
and express the placenta by means of Crede expression. 

Control the uterus fully i^ hours after labor, and always give 
ergot dr. i ; repeat in 30 minutes. 

In 63% of the cases the children are of the same sex; in 37% of 
different sexes. Boys preponderate here as ordinarily. 

There is usually a difference in the development of the twins. 
If they come from one ovum there is not so much difference ; they 
resemble each other closely. A difference of 300 gms. in weight is 
common, it may be 500, seldom more. This is due to the relatively 
better and poorer means for getting nourishment in utero. There 
may be even an intra-uterine struggle for existence. 

In cases of single ovum twins the placentae anastomose, and 
therefore the two circulations. If one heart is stronger than the 
other it does more work, forces the blood further in the placenta and 
thus uses more of the placenta than the other fetus. The heart of 
this fetus atrophies, and finally does no work, but receives blood 
from the stronger fetus and thus becomes a mere parasite. The fetus 
shrinks, does not develop, and becomes sim.ply a little lump of flesh, 
covered with skin. This is called an Acardiacus. 

If the irregular distribution of the circulation occurs later, the 
development of the stronger fetus pushes the weaker one against the 
wall of the uterus, where it is flattened out, becoming a fetus papy- 
raceous. 

It may happen that after one fetus is absorbed, or expelled in pre- 
mature labor, that the other goes on developing and may be delivered 
at full term. Cases are rare, but authentic. It was believed that 
these cases were an example of the fertilization of an ovum after 
one was already developing in the uterus, i. e., Superfetation. 

If we admit the possibility of superfetation we must admit that 
ovulation occurs during pregnancy. Some authorities say this oc- 



NOTES ON OBSTETRICS— JUNIOR CLASS. 19V 

curs. All the evidence is not yet obtained, but for the present we 
may say that superfetation is possible in the human female ; recent 
specimens have shown that it has occurred, though it is rare. 

Superfecundation is the fertilization of ova of the same ovulation 
by different sires ; e. g., a mare covered by a stallion and a jackass, 
throws a foal and a mule. Bitch covered by various breeds of dogs, 
gives a varied litter. 

A white woman may give birth to twins, one white and the other 
black. Still she may have copulated only with the black man. Cases 
are on record where the offspring resembles one parent only. 

From the evidence we may say that it is possible for superfecun- 
dation to occur in the human. 



TRANSVERSE PRESENTATION. 

In those cases where the long axis of the fetus crosses the long 
axis of the mother/we speak of transverse presentation. .It is rare 
that they cross at a right angle. Almost always the fetal axis is 
oblique to the axis of the mother. The head is usually the lower pole, 
but sometimes the breech is lower. 

In certain cases the head is just a little deflected from the inlet 
resting in the iliac fossa; these we call "oblique" positions. The 
breech may also be a little to the side and that is called oblique breech 
position. In German they are called "abgewichene Kopf oder Steiss- 
lagen," i. e., the head has deviated from the median line. 

The term oblique presentation is sometimes applied to those con- 
ditions which we call transverse presentations. 

Since the shoulder is the part to enter the pelvis, is the presenting 
part, they are called shoulder presentations, but the back may present, 
also the side, or the belly. The three latter are very rare. The child 
may occupy the normal fetal attitude, flexion of all members and the 
spine, or it may be lateri-dorsi-flexed, or with the limbs displaced 
or twisted on a longitudinal axis, all of which complicate the diagno- 
sis and treatment. 

Causes of Trmisvevse Presentation. 

In general anything that will prevent the engagement of the head 
in the pelvis, also any condition conferring an extraordinary degree 
of mobility on the fetus, will cause transverse presentation. The cause 
may be primary and lie in some malformation of the maternal parts 
or the fetus, or secondary, being produced by some act or accident 
during labor. 

The most important causes are: 

1. Contracted pelvis. Transverse presentations occur twice as 
often in contracted pelves as in normal pelves. So constant is this 
that when called to a case of transverse presentation must think of it. 
May be a flat or a generally contracted, justominor, pelvis or an ex- 
ostosis. 

2. Anything in the pelvis preventing the engagement ; e. g., 
ovarian tumors, fibroid, the placenta, full bladder or rectum (some- 
times happens that after emptying a full bladder the fetus turns of 
itself). 

3. Twins displacing each other. 

4. Multiparity, hydramnion, premature labor. 



NOTES ON OBSTETRICS— JUNIOR CLASS. 199 

5. Uterus bicornis, uterus arcuatus, partly septate uterus. 

6. Anomalies of the fetus, e. g., double monsters. 

Of the secondary causes, accident plays the stronger role. The 
fetus happens to be in an unfavorable position when the bag of 
waters ruptures, the shoulder is forced into the pelvis, and a trans- 
verse presentation results. The dislocation of a second twin by the 
first is also to be reckoned here. Dislocation of the child by a full 
colpeurynter also. 

Often several of these factors will combine to cause the mal-pre- 
sentation. In some cases the fetus seems to keep its embryonal posi- 
tion in utero, or the uterus is not tense enough to adapt the fetal 
ovoid to itself. 

Posit io)is. 

Although the back or the belly may lie across the inlet, the shoul- 
der is the part which most often enters the pelvis first, so that we 
usually speak of shoulder presentation, the shoulder being the pre- 
senting part. The point of direction is the scapula. The landmarks 
on the shoulder are the scapula, the acromion process, the aA'illa and 
the clavicle. 

There are four positions which the fetus may occupy in utero ; 
in three-fourths of them the back is to the front. 

Scapula laeva anterior, head to left, back anterior. Sc. L. A. 

Scapula dextra anterior, head to right, back anterior. Sc. D. A. 

These are more common, are called "back anterior positions" and 
are much easier to deal with. 

Scapula dextra posterior, head to the right, back posterior. Sc. 
D. P. 

Scapula laeva posterior, head to the left, back posterior. Sc. L. P. 

These are rarer, are called "back posterior positions" and are 
harder to deal with. Thus you see the position of the back and that 
of the head give you the points in diagnosis. 

The fetus lies in utero in the ordinary flexed attitude, the chin on 
the sternum, arms across the chest, and legs on the abdomen. Pro- 
lapse of one arm (the lower almost invariably) frequently occurs. 
Occasionally both arms prolapse, and very rarely simply the upper 
arm. Prolapse of the cord is also not uncommon. As the labor goes 
on the breech comes nearer the head, the shoulder being forced dovv'n 
into the inlet. The child is somewhat twisted. 

Diagnosis. 

Usually this is not difficult. 

Abdominally, (i) The ovoid is not longitudinal, but more or 
less transverse. This is the most important finding. 

(2) There is nothing over the inlet. The hands feel the space 
empty, and may almost come together over the pelvis. 



200 NOTES ON OBSTETRICS— JUNIOR CLASS. 

(3) In the fundus there is no hard part either. But there may be 
some extremities, or the uterus may be depressed in the middle. 

(4) The back is to neither side, but one feels other things. 
These are negative findings, but they generally suffice to make 

the diagnosis of a transverse presentation. 

Scapula laeva anterior. In front v^ill be felt the back, to the left 
in the flank, the head, hard, round, ballotting sometimes. To the right 
side under the liver, the breech with small parts. Heart tones near 
the navel, a little to the left. 

Scapula dextra auterior, similar to the other, but transposed. 

Scapula dextra posterior. Head to the right under the liver, 
breech and extremities in the left flank. No hard, smooth back is 
palpable, but the front of the abdomen is full of small parts which 
are felt very clearly. Heart tones, indistinct to the right and in the 
level of the navel. 

Before the rupture of the bag of waters palpation is usually easy, 
but afterwards the uterus applies itself to the fetus so that it may be 
impossible to distinguish the parts. During pregnancy the diagnosis 
by abdominal palpation is usually satisfactory and the vaginal exam- 
ination gives poor results, while during labor the opposite is true, 
since the contracting uterus covers up the abdominal findings. 

Vaginally. The vault of the vagina is empty, unless some part of 
the fetus has prolapsed. The bag of waters hangs down in the va- 
gina sometimes even to the vulva, and is ''pudding" shaped. The 
cervix hangs down like a cuff. May be impossible to feel anything 
in the vault of the vagina, and th^ manipulations may rupture the 
membranes, which must be avoided. This difficulty of finding a part 
is suggestive of transverse presentation. 

If labor Jias progressed for a short time the shoulder is pressed 
into the pelvis and the finger feels a small, roundish, uneven body. 
If the bag of waters is ruptured, sometimes without this we may dis- 
tinguislpi the landmarks, which are the axilla, the acromion, the 
clavicle. In the axilla can feel the ribs, the "costal gridiron" (Pa- 
jot), the finger gets into the apex and feels the edge of the scapula 
on one side. The scapula may be sometimes reached, or even the 
spinal column. The sharp pipestem-like clavicle is sometimes palpa- 
ble. All these points diagnose the shoulder. 

If an arm or the elbow be prolapsed, the diagnosis is easier. 

Scapula laeva anterior. The acromion process is felt to the left 
side in front. The axilla points to the left side, since, the apex of 
the axilla is in the direction of the head. The finger in the axilla 
feels the ribs and also the anterior edge of the scapula. This point 
gives the position of the back, which is to the front, since the edge 
of the scapula is felt towards the symphysis. This is all that is 
needed for the diagnosis, but feel for the clavicle, which points to 



NOTES ON OBSTETRICS— JUNIOR CLASS. 201 

the belly of the child, and here lies toward the sacrum. If possible 
feel the spine. 

If the arm (the lower) is prolapsed, it will be the right arm in 
scapula laeva anterior ; you will be able to shake hands. If the fetus 
be alive, and therefore have the rigidity of its joints preserved, the 
arm will give you the points necessary for the diagnosis of the posi- 
tion. Thus the palm will be on the side where the belly is, i. e., 
toward the sacrum, the thumb will point to the head, the elbow will 
point to the back ; but it is better to follow up the arm to the axilla 
and get the points in diagnosis from here. 

Scapula d extra anterior. The points are the same, but trans- 
posed ; the left arm of the baby prolapses. 

In Scapula dextra posterior the apex of the axilla points to 
right. The edge of the scapula is found towards the sacrum, and 
sometimes it is possible to feel the spine, near the sacrum. The 
clavicle is in front, the scapula behind. 

The right arm prolapses, the thumb is directed to the right side 
(the head), the elbow points to the left side. 

In Scapula laeva posterior points the same, but transposed ; the 
left arm prolapses. 

Therefore in scapula laeva anterior and scapula dextra posterior 
the right arm prolapses, and having determined this, need only one 
point more to complete the diagnosis, e. g., the side to which the head 
is. If the right arm is in the vulva and the head to the left, it is 
scapula laeva anterior. If the right arm is in the vulva and the head 
to the right, scapula dextra posterior. 

After labor has progressed to a great extent, the vaginal findings 
are made indistinct by the swelling of the parts. The shoulder be- 
comes w^edged into the pelvis and this with the swelling m.akes the 
landmarks hard to find, therefore the advantage of an early diag- 
nosis. 

The arm may be so swollen that it blocks the vagina and then it 
becomes dark blue, suggillated and sometimes gangrenous. 

After the baby is pressed together and forced into the pelvis the 
diagnosis may be impossible unless an arm has prolapsed. When the 
back or belly is placed across the inlet the diagnosis is generally 
more difficult. Skilful men have made mistakes, therefore be warned 
to care. 

Clinical Course of Transverse Presentation. 

These cases are all pathological. True they sometimes terminate 
spontaneously, but the fetus almost ahvays dies and very often the 
mother, too, so that they, are dystocia and always need the interven- 
tion of art. 

Early in pregnancy it is common and even in the latter weeks, 



•202 NOTES ON OBSTETRICS— JUNIOR CLASS. 

occasionally we find the fetus in a transverse position. This almost 
always corrects itself in the few weeks before labor. This process,' 
of which the accoucheur in the majority of cases knows nothing, is 
called self-rectification. 

It does not mean that the fetus puts itself into a longitudinal 
position, but that it finally is brought to a proper position by the 
uterine contractions. This process may be aided bv the proper posi- 
tion of the mother. If it does not take place during pregnancy, a 
longitudinal presentation may be brought about spontaneously dur- 
ing the first stage of labor, or even at the beginning of the second 
stage (very rarely). This is called ''spontaneous version" ; is not 
at all a constant occurrence and in practice is never relied on. 

It is especially likely to occur in hydramnion. Occurs some- 
times, but not so common, in contracted pelvis. 

If neither of these occurs, the transverse presentation persists, 
and unless aid is rendered the labor with its evil results proceeds. 
We find transverse presentation during labor in seven-tenths of the 
cases; just a little more frequently than face presentation (6/io%). 

In order to study the mechanism of transverse presentation we 
will take a case where no aid is rendered. The pains are likely to be 
slow and weak, since no hard- part presses on the cervix. But the 
bag of waters often ruptures early. The lower uterine segment is 
not cut ofif from the general cavity of the uterus, so after the rupture 
of the bag of waters all the liquor amnii escapes, since there is noth- 
ing to hinder it. 

This is a bad accident, especially if the cervix be undilated. 

When the uterus has no more liquor amnii the walls apply them- 
selves to the fetus very closely. Two conditions may now be ob- 
served ; first, there may be no pains at all, the uterus simply lying 
opposed to the fetus, in a condition which was called by Kilian 
''passive contraction." (See MuUer's Handbuch, p. 756, Vol. IL) 
The walls are distensible, the hand can be easily introduced and 
even version performed. This condition carries no danger to the 
fetus or mother, may last a few days, but generally passes over into 
the other state, either spontaneously or as the result of brisk manip- 
ulations. 

This first condition has nothing to do with the so-called tetanus 
uteri, to be described later. 

Sooner or later, usually the result of improper treatment, the 
pains begin, and very soon acquire a dangerous violence. They 
force the shoulder into the pelvis, the fetus is folded together, the 
breech nears the head. 

If the fetus is small or macerated, and the pelvis large enough, 
the uterus, aided by powerful efforts of the mother, may succeed 
in expelling it. This is called "spontaneous evolution," and is the 
last, least likely, and most dangerous method nature has of over- 



NOTES OX OBSTETRICS— JUNIOR CLASS. 203 

coming the mal-presentation. There are two methods of spontaneous 
evolution : 

1. The shoulder becomes fixed, the side of the neck, being ar- 
rested at the linea innominata, the side of the chest is forced down 
alongside the shoulder, then the breech comes down alongside the 
chest, finally the breech is delivered. Now follow the shoulders, then 
the head. The baby is rolled by the shoulder. 

2. The baby is folded together, the head is forced into the 
chest and abdomen, and it is delivered thus, in "'conduplicatio cor- 
pore." 

In both these methods only a small child can be expelled, and 
more likely by the first. Only one or two cases are on record where 
the child was saved. The baby dies of compression or from the 
interruption of the placental circulation, as a result of the continuous 
uterine contractions. These terminations are not to be relied on in 
practice. 

If the fetus is the normal size, the case takes a more serious 
aspect. The pains become irregular, tumultuous, the distinction be- 
tween pain and pause is not marked, the uterus is in a state of con- 
stant contraction. The patient becomes anxious, complains of con- 
tinual pain, great tenderness over the lower part of the uterus, pulse 
and temperature begin to go up. The uterus draws up over the 
child, the muscle becomes thick above the contraction ring ; the lower 
uterine segment is thinned out, till it is as thin as a blotter, and here 
the uterus is likely to rupture. 

This condition is called a "Neglected transverse presentation'' 
and the uterus is in a condition of threatened rupture. The dif- 
ference between the fundus and the lower uterine segment with the 
thinned and dilated cervix, can be seen and felt on the abdomen 
by a groove, running from side to side about the level of the navel. 
Above this groove the parts can be poorly felt, below this groove the 
fetus is easily felt. Unless aid is given the uterus ruptures and the 
mother dies of shock, hemorrhage, or sepsis, from peritonitis. The 
uterus may rupture during an attempt at version. The fetus is 
usually dead, from the interruption of the placental circulation and 
from compression. If not, it dies after the rupture, and may be in 
part or in toto extruded through the rent into the abdominal cavity. 
Or the woman may die of shock and exhaustion before the rupture. 

If the uterus should not rupture soon, and the tendency varies 
with different w^omen (in primiparae not so much tendency as multi- 
parae), the pains get weaker, irregular, the cavity of the uterus 
becomes infected, either from the vagina, from the air, from t-he ex- 
posed arm or from the examining fingers ; the fetus and the little 
liquor amnii left, bes^in to decompose ; gas is developed in the uterus 
and distends it. The condition is called Tympani uteri or Phv- 
sometra. The patient is soon affected by the sepsis. Temperature 



204 NOTES ON OBSTETRICS— JUNIOR CLASS. 

goes up, pulse, also, rapidly, features change, subicterus, and the 
poor woman dies with the symptoms of acute septicemia. 

Another condition that occurs, as well with cephaHc presentation 
as with transverse presentation, is called Tetanus Uteri. It is due to 
too early, brusque and unnecessary manipulations of the uterus or 
cervix, and especially to the administration of Ergot. The uterus 
is in one continual spasm. Occasionally a pain will increase the 
spasm. You find the uterus hard all over, very tender, in continual 
pain ; the cervix is red, dry and hot ; the vagina also dry and hot ; 
there is no secretion. 

Labor is brought to a standstill, since in this condition the cervix 
will not dilate, and it is generally impossible to turn the baby so as 
to extract it. There is no danger of spontaneous rupture, but the 
baby dies, due to the interruption of the placental circulation, and 
unless something is done, the mother dies of sepsis. Treatment 
consists of giving ChCl3 and hot baths, to relieve the spasm, then 
version and extraction. 

Fortunately, in this country, and also in Europe, cases of ''neg- 
lected transverse presentations" are becoming rare, almost unknown ; 
but the evil results of neglect must emphasize the importance of early 
diagnosis and consistent treatment. 

Prognosis. 

This depends on early diagnosis and the attendant, or, in other 
words, on the ease and safety with which the version can be per- 
formed. If it is possible to bring the head over the inlet during the 
latter weeks of pregnancy, the prognosis is the same as usual. 

If during labor you can bring the child into a longitudinal posi- 
tion, the prognosis is only slightly worse than the longitudinal posi- 
tion usually gives. The danger of the operation must be added to 
this. 

In cases where the uterus is threatened with rupture, or has al- 
ready begun to tear, the prognosis is very bad. Almost always the 
fetus is dead, and the mother frequently is lost, also. Such condi- 
tions are among the worst that confront the accoucheur. 

Treatment. 

Version, not watchful expectancy. During pregnancy, if the con- 
dition is recognized, try version by posture. Have the woman, when 
in bed,, sleep on the side to which the head points, e. g., Scapula laeva 
anterior, on the left side. Keep this up for two to three weeks. No 
hurry, there is no danger of premature labor. After the position is 
longitudinal place a suitable binder with pads on either side. In 
France, a girdle called "ceinture eutocique" is much used. My ex- 



NOTES ON OBSTETRICS— JUNIOR CLASS. 205 

peri.ence with this method is not encouraging, the pads with binder 
becoming loose, but often the position rectifies itself. 

If found just before labor and posture has not succeeded, perform 
version by external manipulation. Press the head over the inlet and 
pull the breech in the opposite direction. Then apply the pads and 
binder. 

During the first stage of labor, version by external manipu- 
lation, aided by posture. Put the woman to sleep if necessary, and 
persist with the version till it is completed. After bringing the head 
over inlet force it down, or rupture the bag of waters. (More next 
year.) 

If the case is one of "neglected transverse presentation" you must 
do version by introducing the whole hand into the uterus under 
anesthesia. A foot is brought down at the same timie that the head 
is pushed up. The danger in these cases is that you might bring the 
breech and the shoulder into the lower uterine segment at the same 
time and thus rupture of the already thinned muscle (uterine muscle) 
is almost certain. 

In these cases where version is impossible or is contraindicated 
by the condition of the uterus, we have alternatives. If the fetus 
lives, Caesarean Section ; if dead, embryotomy. 

ERRORS IN THE ATTITUDE OF THE FETUS. 

I Displacements of the Extreniities. 

Prolapse of the hand wdth the head, occurs i in 225 labors. We 
speak of prolapse when the arm has really come to lie before the 
head. 

In these cases where the hand is felt alongside the head inside the 
bag of waters, we speak of it as "forelying." These latter cases 
are not uncommon in the early part of labor. Usually the arm is 
withdrawn in the course of the case and no trouble results. 

Sometimes in a normal delivery you find the hand comes out 
alongside the head, having exerted no influence on the labor, or for 
some delay in the second stage an examination shows a prolapsed 
arm. 

The anterior or posterior arm may comiC down. If the anterior, 
there is more likely to be trouble, since then it gets in the way of 
the anterior rotation of the occiput. If the posterior, it favors 
the rotation of the occiput, by getting between the head and the 
inclined planes of the pelvis. A rare condition mentioned by Simp- 
son, is where one or two arms lie in the nape of the neck. They 
form almost insuperable obstacles to labor, are hard to diagnose and 
very hard to treat. Fortunately, they are rare. Sometimes both 
arms prolapse. Or one~ hand and a foot. 

Pernice, in 2,891 labors, in Halle : 



206 NOTES CN OBSTETRICS— JUNIOR CLASS. 

Hand and ami with the head, 34 times. Two feet and one hand, i. 

Hand and the cord, 5 times. Two hands, cord, 

Both hands, 4 times. One foot, i. 

Foot and hand, 2 times. Face, hand and cord, i. 

Causes. 

J. Anything that will prevent the engagement of the presentnig 
part, e. g., contracted pelvis, tumors, etc., in the pelvis. 

n. Anything that allows th^ lower uterine segment to be incom- 
pletely filled, e. g., face presentation, small child, multiparity. Dead 
children not seldom predispose to prolapse because there is no tonus 
in the extremity. 

HL Accident, (a) Sudden rush of the waters carries the arm 
with it. (b) Dislocation by the passage of the first twin. Clini- 
cally, prolapse of the arms may form an obstacle to labor. The head 
may be prevented from engaging or even a transverse presentation 
be brought about. They may increase the tendency to rupture of 
the perineum, by increasing the circumference of the presenting 
part. By keeping a space alongside the head they favor the pro- 
lapse of the cord. Labor is likely to be slower and art is needed 
oftener. 

Diagnosis. Simple, if the extremity is low down, but sometimes 
it is high up and may be an obstruction to labor. Then diagnosis 
is hard. 

Treatment. If recognized before the bag of waters ruptures, 
posture. Put the woman on the side to w^hich the hand is not pro- 
lapsed. If, after rupture and the arm seems to prevent the head 
from getting into the pelvis, replace with the half hand. 

If, after ihe head has gotten into the pelvis, leave to nature, since 
it has been show^n that there is enough room for both head and 
arm. Forceps operations are much more frequent w^hen the arm 
prolapses, since it increases the volume of the presenting part. In 
applying the instrument be sure not to grasp the extremity in the 
blades. 

Treatment of the prolapse of the two arms the same. 

2. Prolapse of the feet zvith the head. 

This is much rarer. It usually does not cause dystocia, but may 
do so. The feet may prevent the engagement of the head. If the 
head will not engage in the inlet reposition of the foot is indicated. 
If this is impossible you must do version by the feet, which is 
usually very difficult, in spite of the fact that the feet are already 
near the head and over the inlet. 

If the foot has come into the pelvis alongside the head, no treat- 
ment, but watchful expectancy and forceps for pathological delay 
in the 2nd stage. 

Prolapse of the arm in shoulder presentations and of the foot in 



yOfES ON OBSTETRICS— JUNIOR CTASS. 207 

breech presentation (another way of stating foothng presentation), 
already mentioned : 

P-rolapsc of the Covd. 

This is very rare. Occurs i in 400 cases, but the statistics vary 
very much, some authors giving i to 100, i to 800, etc. 
Causes. The same as for prolapse of the extremities. 

1. Obstruction to engagement of the presenting part. 

a. Contracted pelvis, so frequently a cause, that the first thing- 

one thinks of when a case comes up is, contracted pel- 
vis. In primiparae with prolapse of the cord, contracted 
pelvis almost always. 

b. Tumors of the pelvis, etc. 

2. Mal-adaptation of the presenting part to the lower uterine 
segment, e. g., multiparae wdth lax lower uterine segment. Face 
presentation, breech presentation, and especially shoulder presenta- 
tion. 

3. Accident. Sudden rupture of the bag of waters. Delivery of 
1st twin may allow it to prolapse in the second. 

4. Low specific gravity of the liquor amnii ( ?). 

Other causes are, unusually long cord, but, then, very few cords 
are too short to prolapse ; velamentous or marginal insertion of the 
cord with the insertion at the lower end of the placenta. 

Here we have the same divisions of the cases : 

"Forelying" cord when the cord is lying in front of the present- 
mg part, still in the bag of waters. 

"Prolapse" when the bag of waters has ruptured and the cord is 
in the vagina or in the vulva. In some cases the loop may project 
6 or more inches from the vulva. 

The course of labor for the mother is not any different than that 
of the accident which causes the complication. For the fetus it is 
dangerous, as almost always it dies if the case is left to nature. 

Diagnosis. 

Before the bag of waters ruptures one sometimes feels a pulsating 
coil inside the membranes. Distinguished from pulsating arteries in 
the fornices by the count and by the position, they are inside the 
cervix and membranes. A small loop off to the side of the head 
high up may and generally is, in the ordinary examinations, not 
noticed unless some of the signs of fetal asphyxia draw attention to 
the possibility of the condition, e. g., irregular heart tones, and no 
obvious cause for it. Differentiate velamentous insertion of cord. 

After rupture of the bag of waters the diagnosis is easy, usually. 
The pulsating cord can be felt in the cervix, or in the vagina, or 
even be seen outside the vulva. 



208 NOTES ON OBSTETRICS— JUNIOR CLASS. 

In the slowing of the heart tones and the discharge of hquor 
amnii with meconium (symptoms of intra-uterine asphyxia), we 
have other signs which aid the diagnosis. 

P 7-0 gnosis. 

Bad for the child, 95% die if case is left to nature ; 50% die even 
with good treatment. All depends on the cervix, i. e., the rapidity 
with which the child can be delivered. 

Mother's prognosis depends solely on the operations necessary 
to save the child. Otherwise, it is the same as that of the position 
in which the child is found. If the case is left to nature, the prog- 
nosis with reference to the mother is as usual. 

Treatment. 

Before rupture of the bag of waters, posture. Place her to the 
side where the cord is not. After rupture, if the cervix will admit 
the hand, two methods, replace the cord, or version and extraction. 
After rupture but before the cervix will admit the hand, version by 
means of two fingers in the uterus and the hand outside, Braxton- 
Hicks. Version or replace the cord with a catheter. After the head 
has engaged in the pelvis, forceps if the child lives, embryotomy in 
primiparae, if the child is dead. In multiparae, leave the case to 
nature. More later. 

LACERATIONS OF THE PERINEUM. 

There are three grades or degrees of perineal tears usually rec- 
ognized : 

I. When the tear extends through the frenulum and one-third 
the way to the anus. 

II. When the tear extends to the sphincter ani. 

III. Through the sphincter, and upward through the recto-vag- 
inal septum, or toward the coccyx. 

The first two are called incomplete, the 3rd complete, perineal 
tears. 

Tears of the first and second degree occur in primiparae, in about 
15% of the cases; tears of the frenulum alone in about 39%. 
(Schroeder.) My experience the percentages are greater. 

Tears occur more often (i) in primiparae, especially old; (2) 
in multiparae, who have been torn before; (3) where the perineum 
is pathologically altered, e. g., syphilis, fat, edema ; (4) where large 
diameters of the fetus are offered, e. g., posterior rotation of the 
occiput, brow presentation or where the head comes through too 
quickly, as in breech cases; (5) in operations, e. g., extraction by 
the breech. Sometimes the hand may rupture the perineum, or the 
forceps operation; (6) cases of narrow pubic arch; (7) too small 



NOTES ON OBSTETRICS— JUNIOR CLASS. 209 

pelvic inclination; (8) delivery on the back; (9) too broad shoulders 
or carelessness in the delivery of the same. 

The shoulders may tear the perineum, or they may enlarge a 
small tear started by the head. 

Complete perineal tears are rare, they almost never occur with 
normal head presentation ; are most common with breech deliveries, 
particularly in mantial extraction and in forceps deliveries, especially 
the high forceps. These are almost always errors of art, still have 
in rare instances occurred in the best hands. 

The tear generally begins in the vagina, on one or the other side 
of the columna rugarum, sometimes on both sides ; then it extends 
out to the edge of the vagina, now the edge of the posterior com- 
missure begins to give way and the tear extends down through to- 
wards the anus. If it should go further, the sphincter ani is torn 
and the rectum opened, the septum between the A^agina and rectum 
is torn to a variable degree. 

In some cases the tear begins in the skin at the edge of the 
frenulum, and then the perineum splits in the median line ; these 
cases are usually not great and are easy to sew up. 

In a tear of the first degree the frenulum and constrictor vulvae 
are involved. The outlet of the vagina is also torn to a small ex- 
lent. 

In a tear of the second degree the same muscles, plus the trans- 
verse perinei, the lower fibres of the levator ani and the buibo 
cavernosi. The wound extends up into the vagina generally to one 
side of the columna rugarum. 

The sphincter ani is seen crossing the bottom of the wound as a 
pinkish, yellow band about three-fourths inch wide and one-eighth 
inch thick. It can be recognized by the transverse fibres. At the 
sides are the muscles mentioned and one can see them twitching up 
and down. The hemorrhage is usually mild but sometimes large 
veins may be torn or, rarely, an artery. In the vagina the columna 
is pulled to one side and is retracted upward if the tear extends 
on either side. These tears are Y-shaped with a bend in the Y at 
. the point of division, thus seen in vertical section. 



The tissues are soft, tear easily and are suggillated. At the 
edges of the wound there are small tags of skin or mucous mem- 
brane. It may be difficult to distinguish torn surface from the 
bruised vagina, they are so dark and purple. 



210 NOTES ON OBSTETRICS— JUNIOR CLASS. 

In a tear of the 3rd degTee, the same appearances but exag- 
gerated. The sphincter cannot be seen, but the posterior waU of thc 
rectum and anus is visible. To each side can be seen the retracted 
ends of the sphincter, higher up toward the vagina the torn muscles 
which made up the perineal body. In the middle, high up in the va- 
gina, can be seen the edge of the vagino-rectal septum. Feces escape 
uncontrolled and make the wound very dirty. 

Clinical importance, of perineal tears, is great, aside from the dan- 
ger of prolapse of the vagina and uterus, later, perineal tears are 
likely to become infected and may cause severe forms of sepsis. 

In the complete tears the incontinence of the feces is an awful 
accident, often forcing the woman to social ostracism. 

Diagnosis, usually easy. Get a good light, wash blood off with 
1% Ivsol, clean hands. Two pledgets of gauze, separate the labia 
fully.' 

If deep the sterile finger may be passed up into the vagina and 
can feel the extent (this after considerable practice). If blood ob- 
scures the view, pass a pledget of gauze up into the vagina. 

Examine every case of labor for injury to perineum. 

Treatment. 

If the tear is more than one-half inch deep it must be repaired. 
Tears of less than one-half inch may be left to nature. 

If of the first degree, the suturing may usually be done from 
the perineum. 

Isinst have round, full curved needles, a needle holder, a few 
artery forceps, suture material. Of these the best is silk-worn gut. 
For severe tears have 2 vulsella, 6 and 8 inch art. forceps, large spec- 
ula, with long handles, 'and plenty of assistants. 

For ordinary tears often have to operate alone, but if a serious 
tear take time, get assistants and go slowdy. 

Patient on a table. For a few sutures no anesthetic is neces- 
sary, since the parts are so bruized that there is little feeling in 
them. Tear of first degree. 

May begin from below or above. Put the needle in one-fourth 
of an inch from the skin edge, sink it w^ell to the sides of the 
perineum : let it come well towards the vagina and bring it out 
on the opposite side in the same way. 

Place the sutures three-eighths of an inch apart. 

Put them all in before tying. Tie from below upward, tightly, 
because after the swelling goes down they may not be united. After 
being tied, tie the ends all in one knot, one inch from the vulva, and 
cut close to the single knot. 

During the operation use sterile or bichloride gauze for sponges, 
sterilized water or weak antiseptic for solution. 



NOTES ON OBSTETRICS— JUNIOR CLASS. 211 

When the 2nd degree of a tear occurs, the same general rules 
obtain as with the smaller tears. Table, good light, instruments and 
silkworm gut. 

Here it is necessary to make two rows of sutures. One from 
the vagina and one in the perineum. A ball of gauze is passed high 
up in the vagina and then the parts carefully inspected. With the 
fingers adapt the sides of the wound to each other. See if the tear 
runs to one or both sides of the columna, and how far. Begin sutur- 
ing from the top corner. May pass the finger into the rectum, cov- 
ered by a rubber cot. Place the stitches ^ inch apart in the vagina. 
May tie as you go along, but if there is doubt as to how the edges 
will come together, leave untied. Three to eight vaginal sutures 
may be necessary. 

The suture enters the mucous membrane near the edge, goes not 
very deeply in the median line, but at the sides where the levator 
ani has retracted, the needle goes deeply so as to catch these fibres 
and bring the torn ends of the muscle together. 

If the wound is deep here, it may be advisable to unite the pelvic 
floor with buried catgut sutures and then suture the vagina. If the 
tear is only on one side, now suture the perineum as before. If on 
two sides, place two rows of sutures, from the vagina, then sew the 
perineum. 

Xow put in crown suture, taking in skin and vaginal surfaces. 
If the levator ani is torn from its attachment to the walls of the 
pelvis, it cannot be repaired by suture. 

' When the tear extends through the anus the operation is much 
more difificult. 

Pack rectum after lavage, and also 
vagina. Three row^s of sutures, one 
in the rectum, which tie on the rectal 
mucous membrane : one in the vagina, 
and one in the perineum. 

Take plenty of time. Must bring the sphincter together ; there- 
fore, pass the needle deep in the sides. Best to suture the sphincter 
separately with catgut. It is retracted upward and to the side, and 
the two ends must be brought together so as to give control of the 
feces. Place a deep reinforcing suture opposite the suture uniting 
the sphincter ends. Do not forget to remove the rectal or vaginal 
packing. 

After Treatment. Not necessary to tie the legs together. 
Every 5 hours, and after every bowel movement and urination, 
let a pint of 1/3000 HgCU run over the vulva, but allow no washing 
with cotton or sponges. Not unusual for a little odor to the lochia, 
but do not mind this unless very bad. If the odor is annoying, see 
if there are decomposing blood clots in the uterus and vagina or 
other evidences of infection, and if the case is infected the stitches 



212 XOTES ON OBSTETRICS— JUNIOR CLASS. 

must be removed, and the proper treatment instituted. (See Senior 
Notes.) 

On the tenth day remove the sutures. Same precautions as usual. 
In cases of complete laceration give liquid diet for the first few 
days, so that there is no bowel movement. Do not give opium for 
this purpose. Before the bowel movement, which may be attained 
with castor oil on the 3rd day, inject oz. 2 of warm oil into the 
rectum. Immediately after, wash the parts with 1/20CXD bichloride 
solution. 

In general, vaginal injections not to be prescribed. After all 
perineal tears, patient must lie in bed longer, certainly 2 days after 
sutures removed, and in complete tears fully a week, and always 
procure a soft bowel movement, so that the sutures do not tear out 
and the newly healed wound break open. 

Tears of the Vestibule and Clitoris. 

These are sometimes deep and then mav cause bleeding. They 
are due to too strong pressure of the head upw^ard against the rami 
pubis, or too sharply bending the forceps up. Owing to the softness 
of the tissues it may be impossible to tie the vessel, therefore pass a 
suture under it and tie or sew up the wound with deep-laid mattress 
sutures. 

Bleeding from these cases may be considered post partum hemor- 
rhage from the uterus unless a local examination be made. 



PHYSIOLOGY OF THE PUERPERIUM 

After the birth of the child and placenta the woman is a puer- 
pera, the puerperal state has begun. 

The puerperium may be defined as that period which extends 
from the delivery of the ovum till the return of the genitalia to the 
non-pregnant condition is complete. Its length, therefore, is from 
6 to 8 weeks, but in common usage the puerperium means the time 
the woman is in bed after the labor. This is not a good way of 
considering the puerperium, since the woman may get up on the 
third day, and in the Indian tribes she may not go to bed at all. 

The distinction between normal and pathological conditions dur- 
ing the puerperium is not easy, even with the aid of the thermometer 
and of bacteriology. The rapid disintegration of the uterus, the 
changes in the endometrium, and in the open vessels at the placental 
site, are closely akin to the pathological, and would be called such 
if they occurred at any other time or place. 

It is the same approach to the abnormal that renders permanent 
structural changes so prone to begin during the puerperal period. 
After the emptying of the uterus, changes in the uterus and adnexae 
are inaugurated which will finally bring them to their former con- 
dition. The circulation in the pelvis, which has been so full during 
pregnancy, now^ retrogresses, the blood being determined to other 
parts of the body The breasts undergo progressive changes and for 
the next nine months complete the work begun by the uterus. In 
the study of the processes of the puerperium we have to consider, 
1st, the changes in the uterus and genitalia; 2nd, the changes in 
miammae. These are local changes. 3rd, we have the general 
changes, e. g., lungs, heart, skin, kidneys, etc. 

Regressive Changes in the Uterus, or Involution. 

Immediately after labor the uterus is at the level of the um- 
bilicus, sometimes a little above it. The shape of the uterus is like 
a pear with the corners squared off. The uterus is sit- 
uated in the median Ime, but it is likely to be deflected 
to the side, almost always the right, if the bladder or 
rectum be filled. The uterus is in a state of anteflexion 
and anteversion ; it lies against the abdominal wall, resting against 
the promontory of the sacrum behind. 

The walls of the uterus which, before labor, were 4 to 6 mm. 
thick, now are 4 to 5 cm. thick, and a little thinner where the pla- 
centa was situated. (See Fehling. p. 5.) The lower uterine seg- 



214 NOTES ON OBSTETRICS— JUNIOR CLASS. 

ment lies folded somewhat together. The internal os or the con- 
tracting ring of Bandl can be felt. On each side the broad and 
round ligaments hang down loosely. 

The uterus is in a state of retraction. The tonicity of its muscle 
is developed. Every 5 or 10 minutes a contraction occurs and 
passes away. A continual contraction, which Ahlfeld believes, does 
not exist. It is unphysiological ; further, one can feel the uterus 
relax and contract. 

The sinuses of the placental site are partly filled with clots. 
These do not, in normal cases, extend far into the veins but simply 
on the surface and to some depth. If the thrombosis extends beyond 
the uterine wall the case is pathological. If no thrombosis occurs 
the case is also pathological, though bleeding does not necessarily 
occur. 

The walls of the uterus lie fiat on each other, or there may be, 
especially in multiparae, a clot of varying size between them, so 
that ordinarily the uterus has no lumen. 

The uterus is about the size of a fetal head and weighs 2 lbs. 
This varies somewhat with the size of the woman, the dilatation of 
the uterus, etc. 

One sometimes observes, ■ in the first 12 hours after labor, an 
apparent increase in size of the uterus. This is due (normally, of 
course), not to hemorrhage, but to the full bladder (urine accumu- 
lates rapidly since the tension is removed fromi the renal vessels). 
The tonus of the parts reappears quickly and the uterus, which 
sometimes sinks so low in the 3rd stage that the cervix becomes 
visible, rises up higher in the abdomen. From now on the uterus 
grows smaller, the fundus sinks toward the pelvis. This can be 
measured every day with a tape, but the rule of the fingers is good 
enough for practical purposes. The information is of little value 
unless qualified. 

The decrease in size of the uterus begins in the first 12 hours, 
and is regular till the loth day, when it is slower. Any. irregularity 
is due usually to some pathological condition. From the following 
table you can see the size of the uterus, from measurements from 
the top of the uterus to the pubis : 

1st day, 14.5 cm. 5th day, 9.1. 9th day, 6.5. 

2nd day, 12.4 cm. 6th day, 8.3. loth day, 5.9. 

3rd day, 10.8 cm. 7th day, y.y. nth day, 5.5. 

4th day, 9.8 cm. 8th day, 7.0. 12th day, 5.1. 

These measurements were taken when the bladder and rectum 
were empty and when the uterus was held up against the abdominal 
wall, i. £., the anteflexion corrected. 

In practice the fundus uteri sinks below the pubis, or the inlet, on 
the 1 2th day, so that from external palpation it cannot be felt. On 



NOTES ON OBSTETRICS-JUNIOR CLASS. 215 

the 5th day after labor the uterus is 4 or 5 fingers from the pubis. 
After this, it sinks one finger-breadth every two days. 

In women who do not nurse their babies, the involution of the 
uterus is slower, and in cases of sepsis the involution may be ar- 
rested or slowed. 

The rapidity of the decrease in the size of the uterus varies in 
different women, in the same woman at different confinements, and 
the rate of decrease is not even, the most occurring in the first 6 
days, wdien the uterus loses half its weight. At the eighth week 
the uterus may be even smaller than the virgin uterus, and if the 
nursing is continued actual atrophy of the uterus may occur. If 
there are no general symptoms, e. g., pain in the back, nervous dis- 
turbances, anemia, weakness, and if the uterus does not grow too 
small, the condition is not abnormal and the uterus will regain 
its size after lactation ceases. 

The changes in lower uterine segment are less known. Im- 
mediately after labor the cervix hangs in the vagina as a thick, soft 
cuff, more or less torn at the edges. The external os also can usually 
be felt. The cervical canal is large, the walls not so easily felt. 
All the parts are soft, almost like jelly. This serous infiltration of 
the parts disappears very rapidly, even after 12 hours the cervix be- 
gins to form: it shortens, becomes harder. On the 3rd day it will 
still allow the finger to pass, on the loth day no longer. On the 
14th day the finger reaches nearly to the internal os, and in the 4th 
week the cervix canal is a small transverse slit. 

The whole uterus which weighed 1,000 gms. (2 1/5 lbs.) on the 
day of labor, on the 7th day weighs 500 gms., on the 14th day 350, 
and in the 8th week 60 gms. 

The cause of the diminution of the size of . the uterus is the 
changes in the muscular fibres. These undergo a fatty degeneration 
and absorption. Whether the protoplasm alone disappears, the cell 
membrane remaining, or whether the whole muscle cell degenerates, 
is not certain. We also do not know whether during pregnancy 
there is an increase in the number of cells or simply a hypertrophy 
of those already existing. This fatty degeneration of the albuminoid 
constituents of the muscle fibres is Bue to the anemia which exists 
in the retracted uterus and the venous thrombosis. This fatty de- 
generation begins even in the 3rd stage, and possibly in the 2nd 
stage of labor. It proceeds very rapidly. 

The blood vessels of the uterus take part in the involution and 
become thrombotic, or contract, connective tissue develops in their 
interior, the tunica media is fatty, and the vessels thus become ob- 
literated. The process must be well advanced by the 5th day, since 
hemorrhages from the uterus are so rare after this time. The pla- 
cental site takes longer to return to normal than the rest of the 
uterus. It contains the sinuses filled with clots and can be recognized 



216 NOTES ON OBSTETRICS— JUNIOR CLASS. 

thus: the clots feel like little lumps in the surface of the uterine 
wall. The site of the placenta in the 2nd week can be felt as a 
prominent roug'h place, the size of a quarter. 

The changes in the serosa of the uterus are not so marked. After 
the labor the peritoneum, though very elastic, cannot accommodate 
itself to the uterus. It lies, therefore, m folds. These have a dis- 



tinctive grouping, e. g., (Matth. Duncan). After a few days these 
wrinkles disappear. 

Very important changes go on in the Endometrium. 

After labor it is 2 to 5 mm. thick. The decidua or endometrium 
is covered with blood, and the top layer, the cellular layer, is lost. 
It has been taken away on the ovum, the placenta and membranes. 
In forced deliveries of the placenta, the cellular layer may be in part 
retained. Generally, however, the separation occurs in the ampul- 
lary layer, and the surface is raw, the glands being torn and opened. 
The septae covered with their cubical epithelium now necrose to a 
large extent, and most of the glandular layer becomes fatty, de- 
generated and cast off. From the deeper parts of the glands which 
grow closer together as the uterus contracts, regeneration takes 
place, till at the end of two weeks, epithelium covers the septae, 
which have grown up and the glands have been formed. Thus, you 
see, the larger part of the endometrium is cast off, regeneration tak- 
ing place from the connective tissue basis of the mucous membrane, 
and from the epithelium of the deepest portions of the utricular 
glands. 

All these processes connected with the return of the uterus to 
its non-pregnant condition are called Involution. What becomes of 
these dead tissues? The fat molecules from the uterine muscles are 
absorbed in the usual way, probably leucocytosis. May be by means 
of fat-splitting and fat-dissolving ferments. 

The necrotic layers of decidua are cast off by exfoliation, and 
appear in the discharges from the uterus, the Lochia. The bloody 
oozing which occurs after labor, at first pure, later becomes mixed 
with lymph, and is the exudation from the torn surfaces of the endo- 
metrium. 

The discharge from the genitalia of the puerpera is called the 
lochia, and stands in close relation with the changes going on in the 
endometrium. 

The quality of the lochia varies from day to day, depending at 



NOTES ON OBSTETRICS— JUNIOR CLASS. 217 

first upon the admixture of blood, and later upon the greater or 
less number of white cells present. 

On the first day, seldom any longer, the lochia are almost pure 
blood, Lochia Cruenta or Rubra. The presence of clots is pathologic, 
though not necessarily dangerous. 

From now on serum is mixed with the blood, the discharge is 
watery, stained with blood. Lochia Sanguinolenta. This lasts two 
to three days, and gradually the discharges become thicker, of a 
crushed strawberry color and creamy consistency, but the blood does 
not entirely disappear till the 8th or 9th day, and the discharge may 
again be stained with blood when the patient gets up. It is not 
rare to see women with a little bloody flow for three or four weeks 
after labor, and yet be perfectly healthy. The lochia sanguinolenta 
becomes Lochia Serosa about the 5th day, and stain the napkin a 
yellowish color ; the edge may be brown from blood. There is a 
slight disagreeable odor and the vulva is usually a little irritated, 
red. 

The odor of the lochia may be a faded, insipid, or be strong, even 
very fetid, so that the air of the room is tainted. The former varia- 
tions are due to the peculiarities of the patient, the latter to infection 
of the genital tract with saprophytic germs. No importance is to be 
attached to fetid lochia unless there are general symptoms, or there 
IS reason to believe that clots or secundines are retained in the 
parturient canal. 

The lochia serosa get w^hiter, finally yellowish from the admix- 
ture of white blood corpuscles, and are now called Lochia Alba, or 
Purulenta. If there are any cervical or vaginal tears the number 
of pus cells is much greater, lochia serosa occur earlier. Micro- 
scopically. Lochia cruenta contain blood, a few very small clots 
and shreds of decidua. Lochia sanguinolenta, the blood coloring 
matter in a state of solution, red and white blood corpuscles, shreds 
of decidua-micro-organisms of manv kinds. 

The lochia serosa are full of decidual ceUs, large, mononucleated, 
irregular, round or spindle-shaped cells, white blood cells, debris, 
cylindrical and flat epitheium, cholesterin crystals, the trichomonas 
vaginalis and micro-organisms. These exist in enormous numbers 
and, according to Kehrer, even in normal cases, there are pathologi- 
cal .s^enns. Kehrer vaccinated women on the thigh with their own 
lochia and got abscesses of greater or less extent. He innoculated 
animals with the lochia of normal puerperae and in many cases pro- 
duced sepsis, and death. Doederlein produced the same results, but 
found that the lochia as they come from the uterus were without 
bacteria and not infectious, but as soon as they got into the vagina 
all sorts of germs developed Streptococci, staphylococci, have been 
found and all sorts of saprophytes. 

The number and virulence of the germs and, therefore, of the 



218 NOTES ON OBSTETRICS— JUNIOR CLASS. 

lochia, increase up to the 7th day and then grow less. If these 
observations are true, why does not every woman have fever in 
puerperium ? 

I. Because the germs do not develop till the wounds are ad- 
herent or covered with granulations, or do not develop their viru- 
lence. 

11. The uterus, where the greatest wounds lie, is free from 
germs in normal cases, and the stream of the lochia would tend to 
wash them out. 

III. Tlie women possess a varying degree of immunity from 
infection. This immunity may be temporarily suspended from 
anemia, or any severe illness, e. g., eclampsia. 

The lochia alba, or purulenta, contain immense numbers of pus 
cells, of micro-organisms, vaginal and cervical epithelium, a few 
decidual cells and debris ; occasionally a red blood corpuscle, and 
there may also be ciHated columnar epithelium. 

The Qu an tity of the Lochia. 

The amount of the lochia has been estimated for the first 10 
days to be 1,350 to 1,400 grams for primiparae, and 450 to 475 for 
/nultiparae. Three-fourths of this is of the first 4 days. 

In women who do not nurse their babies, the amount is greater, 
and in them involution in general is slower, the lochial discharge 
longer. After operation lochia are greater in amount. Women 
who usually have menorrhagia also have a large quantitv of lochia, 
and too hearty meat diet, as well as alcoholics, increase the amount. 
Also mental excitement. A strong, robust woman is likely to have 
the lochia cease earher than a weak, anemic woman, because in 
the former reparative processes are more rapid. In the latter, fluor 
albus is likely to continue for a long time, thus reducing more an* 
already weak system. 

Source of the Lochia. 

Sometimes compared with a wound secretion, and this applies 
only in part. There is sero-bloody exudate from the placental site 
and also the general endometrium, and from the various tears in the 
cervix. A large part of the flow comes from the glands of the 
cervix, and the vagina, so that the lochia, as they appear, are very 
complex. The secretion of the vulvar glands is also mixed in. In 
order to get pure uterine lochia, it is necessary to wash out the 
vagina and insert a tube through a speculum, into the cervix. The 
lochia are neutral or alkaline in reaction. In the second week they 
become acid. 

Changes in the Vagina and External Genitalia. 
After labor the vagina regains rapidly its tonicity and con- 
tracts. The rugae never become so prominent as they were. The 



NOTES ON OBSTETRICS— JUNIOR CLASS. 219 

mucous membrane is bruised, infiltrated with small hemorrhages, 
some of which are submucous, due to tearing of the connective tis- 
sue. The epithelium is rubbed off in places and there are, especially 
in primiparae, numerous fine tears in the surface. Particularly near 
the vulvar orifice do we find longitudinal wounds of greater or less 
depth and length. These almost always heal by primary union. The 
fluid exuded is absorbed, the blood extravasations also, and the dark, 
livid color of the vagina becomes red. 

After a week the color fades and gives way gradually to the nor- 
mal. It is rare for vaginal tears, even though they are large, not 
to heal. If they become infected or are torn open after being united 
by lymph, they granulate up from the bottom and leave hard scars ; 
this is especially true of the fornix tears, extensions from, the lateral 
cervical tears. 

After labor there is some prolapse of the anterior and posterior 
vaginal walls. This rapidly disappears unless the bladder and rec- 
tum are allow^ed to fill. 

The elasticity of the perineum is re-established with surprising 
rapidity. The swelling of the external genitalia goes down very 
quickly, and the great diminution in the size of the vulvar opening 
is striking. Thus perineal tears, which immedately after labor 
looked large and deep, after 12 to 18 hours are much smaller, but 
they are just as important. 

In primiparae, tears of the fourchette and around the cHtoris 
are very common. There may be minute, three-cornered tears in the 
labia minora, or the crura clitoridis may be torn and give rise to 
hemorrhage. These tears are greater on that side to w^hich the 
occiput pointed. Why ? 

These wounds look at first like any bruised tear, but soon they 
become covered with a layer of whitish lymph, which becomes 
opaque and yellowish with little reddish specks. The wound acts 
like any wound exposed to the air. There is a superficial infection 
and necrosis. It is wrong to call these diphtheritic exudations. On 
the 3rd to the '5th day a layer of granulations appears and the wound 
is granulating nicely by the 7th day. 

Abnormal wound repair indicates a diseased process somewhere 
in the genito-urinary tract, and may be used for the diagnosis of 
sepsis. 

If there is a perineal tear, and it be small, it may unite by 
primary union, or it may granulate up from the bottom. From the 
position of these tears wnth the lochia flowing over them continually 
and so near the anus, infection is very likely to take place. Para- 
metritis, etc., in puerperio is twice as frequent with perineal tears. 
The union of the perineum is not firm until after the 14th day, and 
even later the union may give way. 

Occasionally, on the 2nd to 4th days, the labia swell and be- 



220 NOTES ON OBSTETRICS— JUNIOR CLASS. 

come edematous, especially if any sutures have been placed. This 
goes down under antiseptic washes ; a slight vulvitis, more often 
if the woman is fat or the case not aseptic. 

The external genitalia are left more gaping than before labor, 
the anterior vaginal wall being often visible. The hymen is torn 
deeply and is represented only by a row of small, tags, called carun- 
culae myrtiformes. 

The abdominal walls in many women regain their previous elas- 
ticity very slowly and imperfectly. In a few the tonus is well pre- 
served. A great deal depends on the amount of distention of the 
abdomen before labor and the development of gas in the bowels 
after labor. Attention to this will aid in preventing what the 
women call a "high stomach." The sequelae of insufficient abdomi- 
nal wall support are, enteroptosis, with all its symptoms, pendulous 
abdomen, obstipation, etc. 

Changes in the Breasts. 

These consist in the commencement of the function of lactation, 
whereby the woman is put in position to continue the nourishment of 
her offspring. 

Nature has made woman an exception to the rule of other mam- 
mals. In her the secretion of milk does not begin till the second 
or third day, rarely on the first. In animals the milk is present in 
the glands in the first few hours. This is possibly an outgrowth of 
civilization, in that the function of reproduction is not allowed such 
full play as formerly, and lactation especially has often been neg- 
lected or impossible. The changes occur in the breasts after abor- 
tions from the fourth month on, as well as after labors at term. 

On the second day, or as is usual, on the third day in primiparae, 
the breasts begin to get harder, the veins become prominent, the 
whole organ fuller and heavier; the patient has the feeling that the 
secretion of milk is beginning. Soon the swelling reaches a consid- 
erable degree and the individual milk ducts can be felt as hard 
strings, the lobes of the breasts as hard lumps. The gland is much 
fuller with blood and feels hot to the touch. Rarely it becomes red- 
dened. The milk comes into the breasts with much more rapidity 
in primiparae; they express it as "shooting in" and the distress 
caused is sometimes very severe. 

The woman says that the breasts feel like two hot weights on her 
chest, and if the little extension of the gland which sometimes lies in 
the axilla is involved, the patient keeps her arms outstretched in 
considerable discomfort if not pain. This is attended with a flow of 
milk from the breasts even if the baby does not nurse. At each 
nursing the milk comes with greater force, but after 24 hours the 
process is not so active, still there may be too much milk for a week, 



NOTES ON OBSTETRICS— JUNIOR CLASS. 221 

the binder being- always more or less wet with it. Lesser degrees of 
activity of the breasts are common. 

This swelling of the breasts has nothing to do with inflammation, 
the patient has no temperature or at most one-half degree F. There 
is nothing that could be called "milk fever." 

In multiparae the secretion begins earlier, sometimes even in the 
12 hours after labor, and the breasts do not take on such sudden 
action, but the secretion begins more gradually and seldom do the 
breasts swell so that the skin is stretched over them tightly as in 
primiparae. 

The enlargement of the breasts is not due wholly to milk. It is 
only a small part of the milk that is formed before the nursing, most 
being made while the child is suckling. The distension of the breasts 
is due to the swelling of the gland cells, and the lymphatic engorge- 
ment, both preparatory to the formation of milk. As soon as the 
child begins to nurse the gland cells break down into fat globules, 
the cells produce the milk plasma from the lymph in the distended 
lymphatics, and active secretion is established somew^hat analogous 
to the action of the parotid gland. 

The first milk that comes resembles the secretion that may be 
pressed out in the latter part of pregnancy, i. e., it is watery and con- 
tains yellow streaks. It is called colostrum. 

The colostrum under the microscope is seen to be made up of fat 
globules, a watery fluid, and the so-called colostrum corpuscles. The 
fat globules are often adherent by a thin substance w^hich is visible 
only by means of certain reagents. The colostrum corpuscles^ are 
round, ovoid or stellate cells w^hich sometimes show amoboid move- 
ment , have one to three nuclei which color wath ammonia carmine. 
They often contain numerous fat globules. Where they come fromx 
has been disputed. Believed to be changed gland epithelium or leu- 
cocytes. They remain four to six days and reappear if there is sta- 
sis, or inflammation. In addition, lymphocytes are found, more or 
less full of fat drops, indeed they may be balled together so that they 
can hardly be recognized as white blood cells. 

It is still unsettled whether there is a membrane of casein around 
the fat globules or not. The globules float in a thin almost trans- 
parent serum, which contains a slight amount of albumin. 

Source of the various elements of the milk. The fat comes from. 
the epithelium of the acini in that the cells which at rest are flat 
with a biconvex nucleus become large and cylindrical. Fat appears 
in the periphery of the cell and is thrown off. After several repeti- 
tions of the process the cell itself becomes fatty, degenerates and is 
cast off, a new one being formed from the neighboring cells. 

The casein, since it does not exist in the blood, must be formed 
in the gland. It is thought (Kuhne) that there is a ferment in the 
alveolar epithelium which changes the serum albumin into casein. 



222 NOTES ON OBSTETRICS— JUNIOR CLASS. 

The milk sugar is made in the gland, since it does not exist in 
the blood. If milk stasis occurs, the sugar appears in the urine. 

The fluid parts of the milk come as a special excretion from the 
glandular epithelium. That filtration has much to do with it, is very 
doubtful ; Schroeder says it is a transudation from the blood vessels. 
In addition there are ferments or enzymes in the milk. 

These are necessary for the child; they make the milk a living 
secretion, without which the child cannot thrive. They cannot be 
initiated by the finest chemistry. 

The quantity and quality of the milk varies. 

1st. With the individual. 

2nd. With the race. 

3rd. With development of the body ; a small, thin woman usually 
gives m,ore milk than a large, muscular or fat woman, the same rule 
holding good with cows. Nor does the size of the gland cut much 
figure, the gland lobes may be less than the fat of the organ. 

4th. Nutrition of the patient to a certain degree ; over-feeding 
causes a decrease in the amount of milk, 

5th. Age of the patient. Before 20 and after 30 less and poorer 
quality, before 20 less sugar, after 20 more water. 

6th. Toward the end of lactation the milk gets poor in quality 
and less in quantity, though there are exceptions. 

7th. The milk of the two breasts varies in quantity and quality 
and from day to day, and at different times of the day. 

8th. Hunger decreases the amount of the milk ; fat, casein and 
sugar decrease, the amount of albumin increases. 

9th. Emotions may alter quantity and quality, perhaps give child 
colic, diarrhea, said even convulsions. May produce agalactia. 

loth. Menstruation may alter quantity and quality, perhaps give 
child colic, diarrhea, but this lasts only a short time. 

nth. Pregnancy. Milk gradually dries up, after becoming more 
watery. If nursing is kept up milk may continue. 

1 2th. Drugs often reappear in the milk. This has been known 
since Hippocrates in connection with cathartics. 

One may, in order to purge the infant, give the mother the 
cathartic. Alcohol is said also to pass over, and cases are cited 
where the baby got drunk. Opium has caused 43 hours' narcosis of 
the baby. Iron, arsenic, iodine, lead, mercury are well known to 
pass over. 

Brieger has shown that immunizing doses of tetanus antitoxin 
pass over to the infant. The writer allowed a woman with diphthe- 
ria, who had large doses of antitoxin, to nurse her infant. The child 
did not take diphtheria. Vaccinia is not believed to pass over. 

13th. Disease -has an important effect on the milk. Diarrheas 
cause a diminution ; in cholera sometimes completely. In sepsis the 
milk sometimes dries up, which is a sign of bad omen. 



NOTES ON OBSTETRICS— JUNIOR CLASS. 2-23 

Bacteria can pass into the milk in disease (Kehrer). Tubercu- 
losis, anthrax, may pass over without any change m. the gland, but 
often there exists a pathological process in the gland itself. In mas- 
titis the milk may contain cocci, and pus, which infection may have 
come from the outside or, rarely, from the blood. 

14th. Irritation of the nipples causes an increase of the secretion. 
This is demonstrated clinically in many ways, e. g., by placing the 
baby to the breast early, the milk comes earlier, and by using the 
breast pump too much to "relieve" the breasts there is more milk, 
etc. Massage increases the milk supply. 

15th. Certain foods are said to increase the secretion. Somatose, 
nutrolactose, oysters, gruels. My experience is negative. Liquids 
increase amount of milk. 

Lactation has a not unimportant bearing on the general condition 
of the woman. A certain amount of blood and fat must be elimi- 
nated after pregnancy. Part of those go in the lochia, part in the ex- 
creta and part in the milk. 

If the last is not excreted the other organs must remove the 
excess. We therefore, according to Kehrer, have congestion, especi- 
ally of the genitalia, etc. Fact that when the patient does not nurse 
that the lochia are increased and that the involution of the uterus is 
delayed, but this is generally explained by the absence of the reflex 
irritation which nursing causes on the uterus. Positive observations 
are not on record, but in general it may be said that a woman re- 
covers better from her labor if she nurses her offspring. 

The amount of the milk varies from day to day. Impossible to 
tell how^ much milk is secreted since some flows away, and the baby 
gets only a part. Each day baby gets : 

6 I 7 8 

441 I 501 5i< 

It often happens that when the baby is put to the breast the milk 
flows from the other also. This is due to reflex irritation of the other 
breast. The flow usually ceases after the nursing is kept up for a 
few minutes, sometimes sooner or later. Not pathological. 

General Changes in the Piierpermm. 

During the hours after labor the patient feels tired, but not 
badly. She often sleeps after the room has been ordered and the ex- 
citement quieted down. Within the 24 hours she feels much rested 
and often, in a few days, anxious to get up. If a difhcult operation 
has been performed the time for these changes is lengthened. 

A multiparae is likely to be annoyed by after-pains, i. e., uterine 
contractions. If the tonus of the uterus is marked, as in primiparae, 
the contraction produces little pain if any. The contractions occur 
especially v^-hen the baby nurses — reflex to the uterus from the 



I I 2 I 3 i 4 I 5 
o I 96 I 192 I 234 I 363 



9 I 10 I II day 
621 I 648 I705 gm 



224 NOTES ON OBSTETRICS— JUNIOR CLASS. 

breasts ; also if there are clots or remnants of the secundines in the 
uterus (they cease when the organ is emptied). They occur more 
frequently in women who have had endometritis or one or more abor- 
tions, and after labors where the uterus was much distended and 
emptied suddenly or rapidly, while they are likely to be absent if the 
labor was long and prolonged. They persist one, two or three days, 
rarely longer. If they appear after being absent they usually indi- 
cate a pathological condition, e. g., sepsis. 

The lung capacity of the puerpera is increased, and the pulmo- 
nary resonance is usually clear and pronounced. Respirations are 
not increased in frequency, but respond quickly to anything patholog- 
ical, e. g., sepsis. 

Temperature. 

This has been considered of the greatest importance till recently, 
when the pulse has to a large extent come to be relied on for 
diagnosing diseases of the puerperium. But the best results are 
gotten by a study of the two together. 

Immediately after or during the second stage temperature ought 
not to go above 100.2. Over this one must think of sepsis. The 
severe muscular exertion does not raise the temperature much. After 
birth of the child the patient may have a chill, already considered, or 
it may come after the third stage. Has several causes, sometimes 
due to sepsis and then there is fever. As a rule the temperature 
during the puerperium does not vary much from the usual tempera- 
ture of a woman. 

The temperature which may be considered normal is put differ- 
ently by the various authorities. Fehling says 38.4 C. (loi.i F.) ; 
Winchei, 100.7 J Boxall, of London, 100. It is to a great extent arbi- 
trary. My own experience is that if the ternperature rises above 99 
F. there is usually some cause for it and always (almost) a mild in- 
fection. In a case which you treated yourself and where you know 
the nurse, the temperature should not rise above 99.5 and many cases 
will not show a rise above 98 6-10. 

In the first 12 hours after labor there is usually a rise of one-half 
a degree. If the labor terminates in the morning, this added to the 
usual afternoon rise. If in the evening, the next morning tempera- 
ture is not much changed. 

There is a variation between morning and afternoon temperature 
of 1° F., seldom more. Larger variations in primiparae. But there 
is not much difiference (if any) in the temperature between primi- 
parae and multiparae. 

There is no such thing as milk fever. Formerly, in the non-anti- 
septic days, almost every puerpera had fever on the third day. Since 
at this time the breasts got large and hard, the fever was ascribed 
to the violent coming of the milk, and the real cause, the infection of 



NOTES ON OBSTETRICS— JUNIOR CLASS. 225 

the genitalia, was overlooked. With the advent of antisepsis there 
has been a great decrease in this milk fever, and large numbers of 
the best authorities deny its existence. 

Dr. Jaggard said he had never seen a case where there was 
fever and no other cause to be found than simply the coming of the 
milk. I have seen primiparae with the breasts standing out hard and 
firm, the axillary lobe of the gland so swollen that the patient had 
to keep the arms from the sides, and yet the temperature 98.6. If 
there is infection of the breasts it is another thing. Milk fever is a 
term that should be abolished from obstetrics. It too often forms the 
cover for severe puerperal fevers and many a woman has lost her 
life because of the term. 

The temperature of the puerperal woman is subject to fluctuations 
on very slight causes as compared with the non-puerperal woman. 

The reason usually given that the puerperal woman should have 
some fever is this : The products of the regressive metamorphosis 
of the uterus and all the genitalia absorbed must be oxidized. This 
increased oxidation causes the increase in the body heat. But nature 
has a very good way of regulatmg this. By increasing the perspira- 
tion and other excretions the temperature is kept nearly normal. 

Said that mental shock and emotion can give high temperature, 
some cases seem to prove this, but be careful to shut out everything 
else. Have never seen an unequivocal case. Constipation sometimes 
gives rise to temperature, which goes down when the bowels are 
emptied. This is probably due to obstruction to the flow of lochia, 
which is overcome when the bowel is emptied. It is safest as soon 
as your puerperae have fever to think of infection first. 

The Pulse. 

In the second stage of labor the pulse is high, rapid, irregular, 
but during the third stage it calms down and is normal during the 
time unless there is severe hemorrhage, when it becomes small and 
rapid. Immediately after the labor the pulse is soft, but soon has a 
high tension, especially in multiparae. 

• A very high tension slow pulse must be regarded as a warning 
of eclampsia. 

A peculiar phenomenon is sometimes observed in healthy puer- 
perae. The pulse rate may be as low as 40 a minute and some 
observers have found 30, but this is very rare. It occurs after labors 
at term more than after early abortions ; in multiparae more often 
than in primiparae. 

The cause is not known. There are many theories, of which the 
most plausible are : Fehling's — the sudden diminution of the intra- 
abdominal tension irritates the vagus reflexly ; Schroeder's — the 
heart, which hypertrophies (perhaps) during pregnancy, now need 
not work so hard ; Olshausen's — the fat which is absorbed from the 



220 NOTES ON OBSTETRICS— JUNIOR CLASS. 

uterus slows the heart. Further, the horizontal position, the quiet of 
the patient, the less amount of food, etc., may conduce to the slow 
pulse. It is of great prognostic significance in that a pulse which is 
slow means that everything is going along nicely. 

A very rapid pulse in the puerperium, in the absence of fever, 
points to hemorrhage (recovery from severe hemorrhage) or some 
heart disease. Not seldom a rapid pulse draws attention to the con- 
dition of the heart, but be careful in the diagnosis of heart disease 
in pregnancy and puerperium because murmurs are common. 

The arterial tension at first decreases, later is increased. 

The Blood. 
There is a decrease in the amount of blood which had increased 
during pregnancy. This decrease is due to, hemorrhage during 
labor, the lochia, sweat and other excreta. In the first days after 
labor there m.ay be a decrease of both reds and whites, but soon the 
whites begin to increase and a slight leucocytosis may be observed. 
In general, the blood changes are not well known. 

The Skin. 

All the functions of the skin are more active, the sweat glands 
particularly. After labor, when the patient is well covered up, she 
breaks out with a full warm sweat which may be so profuse that it is 
considered necessary to change bed linen. This is so frequent that it 
is considered normal, but there is no doubt that it is favored by the 
warm covers and the administration of warm drinks. That there is a 
sweating pecuHar to the puerpera is not true. 

The tendency to perspiration is less in the latter days, probably 
due to the establishment of the milk and free lochia. 

The laity have great fear that the patient takes cold. This is the 
outgrowth of the old belief that puerperal fever comes from catching 
cold, and it is still said among the midwives, so that it is not unusual 
to find the windows closed and the patient covered with blankets, 
even in summer. 

Ahlfeld says that there is some connection between the appear- 
ance of the sweat and the contraction and retraction of the uterus 
after labor. The puerpefa has a peculiar odor, which varies in health 
and disease. 

The Kidneys. 

Relieved suddenly from the increased intra-abdominal pressure, 
the kidneys become active. In the third stage it is not rare to find 
the bladder full and even overfilled, making an obstacle to the deliv- 
ery of the placenta. The urine contains frequently a little albumin 
white blood corpuscles, a few reds and scattered hyaline casts. In 12 
hours these disappear from the urine. The amount of the urine for 
the first eight days is 3 to 400 grams more than that of the non- 



NOTES ON OBSTETRICS— JUNIOR CLASS. 22*7 

pregnant woman, but is not much more than that of the pregnant 
woman in the latter months. (Kehrer.) 

Specific gravity varies from 1014 to 1016, according to the 
amount of urine. The amount of urea varies. On the first and sec- 
ond days, moderate ; greatest on the third day, and now continues at 
a high percent during lactation. The increased metabolism of lac- 
tation (i. e., the change of albuminoids into fat) gives the increase 
of urea. On the third day to 2.6% ; after, 1.6% to 2.2%. The pro- 
portion of salts, NaCl, phosphates, sulphates is not much different 
from the usual. 

In addition to the ordinary urinary constituents, milk, sugar and 
peptones have been found. Milk sugar is present physiologically — 
Blot first called attention to it. It is due to the absorption of the 
sugar from the milk. The amount of sugar is seldom over 1%. It 
is a good sign in the urine, showing an abundance of milk. 

Peptone has been found very often in the urine from the second 
to the tenth days, after this disappearing. This is due to the degen- 
eration of albuminoids in the uterus," and is evidence of the necrosis 
of a certain part of the uterus with absorption. Albumin is found 
sometimes for a few days after labor, but in very slight amount. 
As a rule, however, albuminuria after the first 48 hours must be sus- 
pected. Urine must be drawn with catheter to avoid contamination 
with the lochia. After kidney disease in pregnancy, albumin disap- 
pears quickly, perhaps entirely. Further, there may be albuminuria 
after narcosis with ChClg or ether, a fact not to be forgotten. But 
this disappears quickly unless there be some previous nephritis ; 
often the albumin comes from a slight catarrh of the bladder. 

Pathologically albumin occurs after labor in pyelitis, sepsis, etc. 

In the first 12 hours there is usually retention of urine. This is 
due to the lack of elasticity of the bladder, the horizontal position, 
the swelling of the vulva and urethra, sometimes to kinking of the 
urethra (Olshausen). Still quite a percent pass urine spontaneously. 
In many cases it is necessary to use the catheter. As a rule patients 
pass urine three times daily, much less often than in the later months 
of pregnancy. 

The Weight of the patient undergoes marked changes in the first 
months after labor. According to Gassner, the average weight of 
238 women on the day after labor was 124 lbs. In the puerperal tv/o 
weeks they lose about 9 lbs. or 8% of their weight. The loss is 
greater in multiparae, greater in large women, and after normal than 
premature labor, also greater after twins. Should she put on flesh, 
the milk is likely to dry up. This great loss of weight is due to (i) 
the moderate amount of food taken, and (2) the great amount of 
excreta, the sweat, the urine, but especially the lochia and the milk. 
This is the reason women look thin, pale and washed out after get- 
ting up, and need a tonic diet. Regains her weight in four to six 



228 NOTES ON OBSTETRICS— JUNIOR CLASS. 

weeks. Nowadays, since we do not starve the woman so much in 
the puerperiiim, these losses are not so marked, but the custom of 
feeding puerperae very Ughtly still exists in many places. 

The Intestinal Tract. 

The appetite is at first not very strong, but the patient wants 
water and drinks a great deal. Reason is f)lain. Soon she demands 
some solids, and one need not refuse her (see later). The abdomen 
after labor has a concavity. The uterus can be seen as a hard prom- 
inence over the pubis, but from the navel to the ensiform the surface 
is usually concave. Soon this fills out. Sometimes tympany devel- 
ops, but this goes down in one or two days. If the bladder is full 
you can see two tumors, one above and to the right of the other. 
You may often see and feel the coils of the intestine and the peris- 
talsis. If a multipara this is especially plain. 

Constipation is very common. Very seldom a bowel movement 
before the third day, and then usually with some castor oil. You 
may be able to feel the sigmoid flexure full of feces. Constipation 
is due to weak peristalsis, from the quiet of the patient, also the 
weakness of the abdominal muscles, which have been stretched so 
much, and further, the fluids of the feces are absorbed as the excre- 
tion of fluids is great. 

Diarrhea is very rare in normal puerperae. 

The Nei'vous System. 

The mental condition of the woman is one of increased excitabil- 
ity. Slight irritations have a great effect on her. This was known 
to the Romans and they had a sign before the door so that she was 
not disturbed, even by the tax collector. 

Bad news, it is said, can give the woman fever. If there is a her- 
editary taint in the family as regards insanity, it may come out now 
and cause one of the numerous psychoses of the puerperium, usually 
melanchoUa. After eclampsia these are not rare. 

The puerperal woman hears more acutely and is more sensitive 
to light, and according to Dionis, to bad odors ; her reflex excitabil- 
ity is also increased. 

'Recent investigations of the knee jerk in pregnancy, labor and 
puerperium show that the reflex is more active than usual in preg- 
nancy, most active in labor and at the height of a pain, while the 
excitability gradually passes during the puerperium. 

Diagnosis of the Puerperium. 

Of course rarely any difliculty, the history being given, but in 
medico-legal cases it may be necessary. One must be very careful 
because the diagnosis is not always easy and only rarely can one 
assert with positiveness either fact. 



NOTES ON OBSTETRICS— JUNIOR CLASS. 229 

Get the history from friends of the patient, e. g,, gradual enlarge- 
ment of the abdomen, usually called dropsy ; then sudden diminution, 
sudden illness, or incapacity for work ; nausea and vomiting six 
months ago ; bloody bed clothes, etc. Still this could come from a 
polyp or something else. 

General Examination. Pigmentation, striae, loose, flabby abdo- 
men lends a suspicion, more or less strong, depending on the degree. 
Presence of blood, meconium or vernix caseosa has great impor- 
tance. Look also on the linen of the patient and bed. 

Local Examination. Breasts : size, follicles, milk, especially co- 
lostrum. But this is not certain, since in multiparae can get some 
milk almost always ; the amount of milk is significant. 

Genitals give the most positive information, but then, too, only 
in primiparae. Depends greatly on the time elapsed since the labor. 
The labia are large, soft. Tears of the labia and hymen are impor- 
tant, but the tears of the hymen must be deep, because coitus tears it 
as a rule. If there is a fresh tear of the perineum the diagnosis is 
easy, if no operative treatment have been pursued. If the baby was 
small, especially if macerated, there may be no tear of the hymen 
even. 

The condition of the wounds and the discharge, shreds of decid- 
ua, decidtml cells, the lochia, if the labor be not long passed, give im- 
portance in conclusions. The large, loose and blue condition of the 
vagina lasts about one week, the rugae are never so prominent. 
Later the vagina is bright scarlet and velvety, bleeding easily. 

The cervix shows the bilateral tears. The shape of the external 
OS is changed from a cone with a round hole to a cylinder with a slit 
in it. Still some virgins have a slit-like orificium. 

The uterus is large, soft, depending on the day of the puerperium ; 
and in anteflexion. The cavity is large and if one can insert the fin- 
ger, may feel the placental site, round, irregularly rough, which is 
positive. The cervix is very red and has many papillary erosions in 
the process of heaHng. Hegar's sign is present after the fourteenth 
day for several weeks. 

The answer to the question, how long ago did the woman have 
her baby? is verv hard, and depends on the character of the findings, 
especially the condition of the wounds and the size of the uterus. 

To answer, was the child viable? is still harder. Severe injuries, 
many striae, i. e., the signs that the uterus held a large body and a 
large body passed through the genitals. 

After abortions it may be impossible to tell the condition with 
positiveness. 



THE NEW-BORN CHILD. 

The most important part of a child's Ufe is that part spent in 
iitero. The Hfe is simply one of growth. It has been said that the 
fetus lives in a state of "dreamless sleep." This is not probable ; 
rather we believe that the fetus has periods of rest and activity. 
That the fetus drinks liquor amnii there can be no doubt, and other 
movements have been diagnosticated ; hiccough is one and a not 
infrequent sign of intra-uterine life. 

Sometimes the women say that they can feel the fetus stretch 
himself, ''sich recken," as the German women say. Weber, in Mar- 
burg, has described movements of the chest of the fetus which bear 
resemblance to nothing else but respiratory movements. These I 
have observed twice — slight up and down movements over the chest 
and back, about 50 a minute, not synchronous with the heart of the 
mother or that of the child. These respiratory movements ;'are too 
superficial to cause anything to be sucked into the lungs, but- enough 
to keep up the circulation in the chest. The metabolism of the fetus 
is relatively simple, but such as it is, it is very little understood. 

The change from intra to extra-uterine existence is a very sudden 
one and is attended with a severe shock to the child, which in some 
cases it does not withstand. It may happen that the child is not 
properly developed to assume an existence in the world, e. g., mon- 
sters or infants with congenital heart disease. What concerns us 
are the changes which take place and the physiology of the first 
days of life. 

The change from the state of apnea in which the fetus exists be- 
fore birth to external respiration has been already considered. (See 
Physiology of Labor.) 

At first the baby breathes very irregularly, any marked breathing 
being usually attended with kicking and movements of the arms. 
The crying of the infant is beneficial, since it serves to expand its 
lungs. As it is, the lungs usually do not expand fully for several 
days. The respirations are both superficial and deep, the two alternat- 
ing. Expires from 39 to 47 c. c, average 45 c. c. A slight rattling 
can often be heard for several hours after birth. This is due to mucus 
from the vagina which has been sucked m, or to an increased secre- 
tion of the throat due to congestion during labor. It is important in 
that it may give rise to brocho-pneumonia (rare), or if swallowed, to 
enteritis (common). It is three or four weeks before the respiration 
is regular and even, but is still subject to quick fluctuation. 



NOTES ON OBSTETRICS—JUNIOR CLASS. 231 

The respiration is at first thoracic, later mixed, but in patholog- 
ical cases (asphyxia) may be abdominal. Whining is not normal, 
and occurs in puny, premature babies or such as have been severely 
injured during difficult extractions. 

The Blood. 
Is more concentrated, contains more hemoglobin than the adult. 
It contains a few nucleated reds, and a large number of whites, be- 
ing quite marked at first. The nucleated reds soon disappear. 

The Pulse. 
During fetal life it is 120 to 140; immediately after birth it sinks, 
but rises, ^nd within an hour is 130 to 144. Soon 120. During the 
ensuing days there is a slight increase in the number of pulse beats, 
but after the first month there is a decrease. The pulse is irregular 
(Vierordt) in frequency and in strength. 

The Temperature 

Of the fetus in utero may be one-half a degree F. higher than that 
of the mother taken in the vagina. This is because the fetus has its 
own metabolism. 

Immediately after the labor it sinks often two degrees F., especi- 
ally if the fetus be allowed to lie exposed in a cold room. In 12 to 
24 hours the temperature rises again to 98.8 or thereabouts, and 
stays here with slight evening variations, which are irregular. 

Slight causes in the new-born can raise the temperature, e. g., 
crying, digestion, and slight exposure to cold or dampness lowers it. 

Uriue. 
Varies very much in different children, and there is no rule. 
Amount found in the bladder at birth varies from 7^ to 9 cc. 
The total amount of urine in the early days has recently been esti- 
mated by Reusing. 

I 2 3 4 5 6 7 8 day. 

18.9 38.6 64.9 84 ^21.5 147 175.5 217.2 c. c. 

The amount varies with the size of the child (smaller in premature 
children), and with the food, if mother's milk, smaller amount of 
urine ; the bottle-fed, large amounts, since they receive more fluid. 
Infants pass more urine in proportion to their weight than adults. 

Specific Gravity about 1006 on the first two days ; goes up to 
1012 on the third and fourth days, then sinks to 1005. 

The color is watery, clear, but gets yellower soon, seldom deeper 
than straw. 

The reaction is acid, and the urine not seldom contains albumin, 
hyaline and epithelial casts and uric acid crystals, the first few days. 
Sugar, according to Pollak, is not uncommon in normal urine. 



232 NOTES ON OBSTETRICS— JUNIOR CLASS. 

The percent of urea is highest on the third and fourth days, 
I i-io% ; after this it sinks to 8-io%. These figures are large, later 
investigations by Martin and Ruge give one-fourth these amounts. 
The percent of uric acid is large, and explains the frequent occur- 
rence of uric acid infarct of the kidney. This appears as a brownish 
infiltration of the papillae of the kidney, which grits a little under 
the knife. Formerly believed that the deposit in the kidneys was acid 
soda or ammonia urate, but now believed to be pure uric acid. The 
deposit which appears on the diaper as a reddish stain occurs more 
often in icteric children (Hofmeier). In these the amount of urine 
is small, also. In children who receive a large amount of water the 
''infarct" is rarer. 

General Condition. 

Observing the child after birth, it is seen to be in a half sleeping- 
state. The eyes are opened once in awhile, but immediately closed, 
the arms move, also the legs, sometimes quite vigorously. The differ- 
ence between sleep and waking is not very well marked till the end 
of the first week, or even later. . Of the special senses, touch and 
taste are already well developed. The sight is already developed; 
the light reflex is certainly present. Hearing is developed as early 
as the first day. The sense of smell develops later. 

The Intestinal Tract. 

Shortly after birth the meconium is discharged. This is due to 
the presence of gas in the bowels (from air swallowed) and to peri- 
stalsis, which becomes active after birth, perhaps due in part to the 
partial asphyxia which the child undergoes during birth. The me- 
conium continues for two to three days and then becomes brownish, 
later yellow if the baby is fed at the breast. The yellow stools con- 
tain large numbers of bacilli, and the Bact. Coli. Com. It is said 
that these bacteria are useful in helping to split up various constitu- 
ents of milk. The movement normally is like soft homogeneous 
putty, of a golden yellow color. 

It is said that the stomach of the new-born is placed vertically or 
parallel with the long axis of the body. In several autopsies I have 
found the stomach in the same position as in the adult. Normally 
the infant passes two stools a day. but if the bottle be used, there 
are more. They then contain whitish particles of undigested casein, 
and greenish mucus. There is also an odor which is distinctly sour 
or may be fetid. Normally no mucus should be seen, and the water 
stain a half inch around the edge of the solid part of the stool. 

The stomach contains pepsin, and the pancreas contains trypsin 
and the fat splitting ferment, but no diastatic ferment (Zweifel). 
All these are present in small amounts. The colostrum has a slightly 
purgative action which is due in large part to its indigestibility. 



NOTES ON OBSTETRICS— JUNIOR CEASS. 233 

Weight. 

The infant loses in weight for three to four days. The loss is 
about 220 gms. ; is greater in bottle fed than breast babies, and when 
the cord is tied late. 

The original weight is regained by the tenth day, often later, and 
from now^ on the gain is continuous. The loss is due to the excreta 
— meconium, urine, evaporation — and also the fact that the new- 
born gets very little nourishment in the first few days. 

This does not occur with animals and has an important bearing 
on the diseases of early infancy. 

First day loses 139 gms. 

Second day loses 64 gms. 

Third day loses 33 gms. 

Fourth day gains 50 gms. 

Fifth day gains 50 gms. 

Sixth day gains 36 gms. 

After this about an ounce every day for ten days, then less. 
These figures will vary very much in individual children. Some 
lose little. Some lose quickly and regain quickly ; others regain 
slowly. 

The Skin. 

The Skill presents many changes. At first the baby is cyanotic, 
especially the face. The eyelids are not rarely swollen. In a few 
minutes the color becomes red. The vernix caseosa dries up, the epi- 
thelium scales off in branny scales, or there may be pronounced 
desquamation. The skin underneath looks at first a little raw and 
may crack, but soon a nice healthy pink or white appears. The eye- 
lids especially, if washed roughly and almost always if AgNo., be 
used, are red and sw-ollen ; may secrete for a few days, or the lids 
may be even stuck together. 

The skin is liable to eruptions, especially of tiny vesicles with 
watery or slightly cloudy contents. This used to be called strophu- 
lus. Or the vesicles may be surrounded with red borders or the 
redness may be present with few and scattered vesicles. They are 
usually due to the too free use of water and soap, and heal rapidly 
when the causes are removed. Heat also causes an eruption. 

A prominent and frequent change in the skin is Icterus Neona- 
torum. 

A large number of children (80%) have jaundice in the first days 
of life. Under aseptic conditions the percentage is lower. Less than 
40% at the Qiicago Lying-in Hospital. We distinguish two forms, 
Icterus Gravis and Icterus Simplex. Jaundice may occur as a symp- 
tom of various diseases of the early days, especially sepsis, and also 
the hemorrhagic diathesis and Buhl's disease. Our attention is 
directed here to the simple jaundice, or Icterus Neonatorum. 



234 NOTES ON OBSTETRICS— JUNIOR CLASS. 

S'pnptoms. 

About 40% of new-born children become icteric. The jaundice 
begins on the second day, but may appear later, but seldom any 
earlier. The face and body are first colored, and if the case is severe, 
the conjunctiva. It disappears usually at the end of three or four 
days, but if the sclerae are colored^ it takes longer. The skin is usu- 
ally a little red and may hide the yellow. Sometimes stays four 
weeks. Press the blood away and the finger mark is yellow. Where- 
as in the icterus from obstruction of adults the sclerae are the first 
affected, here they are affected late, and indicate a severe case. The 
internal organs, especially the intima of the arteries, also the carti- 
lages and interstitial tissues are usually icteric. The brain and cord 
slightly, the liver and spleen very little if any. The kidneys almost 
always contain the "uric acid infarct." 

The cases of jaundice are not limited to any district, to private or 
hospital practice. Seen more frequently in the babies of primiparae 
and in boys more than girls, and especially with children that pre- 
sented by the breech. Premature and atelectatic children especially 
liable, also operative cases. 

Generally the child suffers no change from this condition. The 
urine may be a little brown sometimes. But examined more care- 
fully, one finds that severely jaundiced children grow less rapidly 
than the others, lose weight, perhaps have fever, are colicky. Oxi- 
dation processes m@re rapid. The excretion of uric acid and urea is 
greater (Hofmeier). Therefore more albumin used up. Bile pig- 
ment has been found in the urine. 

Etiology. 

Formerly considered either hematogenic or hepatogenic. But now 
known that both factors operate. The bile acids have been found in 
the fluid of the pericardium, therefore the liver must enter into the 
causation. There is no doubt that in the blood of the new-bom 
children there is great destruction of red blood corpuscles, and if 
this is so, there is more material for bile. But some authors claim 
that the degeneration of the red blood cells is due to the presence of 
bile. Admitting that there is a greater destruction of red blood cells 
than there usually is, and therefore an increase in the amount of 
bile, why is this absorbed? 

There are many theories, e. g., obstructions of the(i)ductus chole- 
dochus by mucus, or epithelium or (2) edema of Glisson's capsule, 
(3) changes in the circulation of the blood in the liver, (4) absorp- 
tion of the bile from the intestines, which may take place directly 
into the blood or the general circulation as a result of the persistence 
of the ductus Arantii. 

Infection has been given as a cause, and for severe cases is usu- 



NOTES ON OBSTETRICS— JUNIOR CLASS. 235 

ally active. The prognosis is good, but in weak children, especially 
premature infants, it may not be so good. Of course, if the jaundice 
is a symptom of some severe disease, e. g., sepsis or syphilis of the 
liver. Buhl's disease, etc., the prognosis is bad. Treatment for the 
lighter form is nil. If severe, especially if the infant be premature, 
careful nourishment. Often there are symptoms, too, of intestinal 
fermentation, indicating calomel, flushings and regulation of the diet. 

LOCAL CHANGES. 
Separation of the Cord. 

The cord is inserted into the belly of the child, the vessels pass- 
ing through the abdominal wall, the amnion covering the cord be- 
coming continuous with the skin. The skin is usually prolonged 
upon the cord for a short distance, sometimes half an inch, called the 
skin navel. Rarely the amnion forms part of the skin near the inser- 
tion of the cord, amnion navel. Vessels from the arteries of the abdo- 
men make a circle around the navel, send up tiny branches, which 
end about i-i2th inch on the cord itself. The piece of cord not in 
connection with this circulation must necrose and fall off. At the 
point of union of the dead and living tissue a reactive inflammation 
occurs, a line of granulations forms and the piece of cord is grad- 
ually separated from its base. 

There are two ways in which the cord behaves; ist, mummifica- 
tion; 2nd, moist gangrene. The first occurs when the cord is kept 
warm and dry, the second when being wrapped in oily dressings the 
evaporation is prevented. The drying-up of the cord is more com- 
mon, and is to be favored. A large thick cord dries up late, and some 
authors advise to strip all the jelly of Wharton from the cord, so as 
to favor the rapid mummification. 

After a few hours one can see evidences of a reactive inflamma- 
tion, the skin around the insertion of the cord is red and swollen. 
White blood corpuscles wander out and soften the cord at its junc- 
tion with the body till a layer of granulations is fully formed. The 
cord finally drops off, the arteries first and then the vein. The sur- 
face of the navel is covered with very fine granulations, the center 
is retracted, the sides falling in, epithelium forms over the surface 
very quickly and the navel is cicatrized. The cord drops off from 
the fourth to the twelfth day. The majority of authors give the 
average as the fifth day. Our experience has been much different, 
with the older methods of treatment of the stump, it being excep- 
tional for a cord to drop off before the end of the week. Now the 
cord is tied close to the insertion in the skin (but not involving it), 
and under aseptic treatment falls off in three to six days, seldom 
later than the eighth. 



236 NOTES ON OBSTETRICS— JUNIOR CLASS. 

The retraction of the center of the wound is due to the retraction 
of the intra-abdominal part of the arteries. The heahng of the navel 
is complete on the third or fourth day after the dropping of the cord. 

The umbilical vein collapses, the walls adhere, but there is no 
thrombosis normally. The hypogastric arteries collapse and owing 
to the thick muscular layer are quite obliterated, but a small clot 
almost always is found in them. This should not present the appear- 
ance of pus normally. 

The separation of the cord takes place earlier in large, strong 
children, later in premature children. Earlier in healthy children, 
later in sick children. Later if wet, earlier if drying up of the cord 
is favored. 

The staphylococcus and streptococcus and various non-pathogenic 
bacteria have been found in a large proportion of cords of healthy 
children. They were much more in quantity and much earlier found 
when gangrene of the cord occurred. The method of dressing the 
cord had a great deal to do with it. 

The new-born child presents the various changes of its body due 
to the operation of the factors of labor. The form of the head has 
been spoken of. Even after 12 hours the change toward the normal 
is marked. At the end of '/2 hours the form is usually the same as be- 
fore labor. If there is distortion after seven days the asymmetry is 
congenital. If the child came by the breech with the feet along the 
face the doubled position may persist for several days. 

The Breasts of some new-born children show an interesting phe- 
nomenon. On the third or fourth day they enlarge, become hard and 
occasionally secrete a little watery milk with yellowish streaks, 
^licroscopically it resembles the colostrum, and the colostrum cor- 
puscles may be found. On the fifth or sixth day a fluid resembling- 
milk in color and taste may be pressed out. This continues for two 
to four vv'eeks if the gland be irritated, but if left alone the secretion 
dries up and disappears. In rare cases a little fluid can be expressed 
after a year. This condition must be distinguished from true mas- 
titis of the infant, a disease which does occur. The secretion is called 
by the Germans Hexen-milch, AVitch's milk, and occurs in boys as 
well as girls, really it seems oftener in boys than girls : in weak as 
well as strong children. The breasts should be left alone. Wash 
them with soap and water, pad them lightlv with cotton and tie a 
bandage over them. Do not squeeze them. 

In about one case out of twenty the female infant will present a 
phenomenon resembling menstruation. The flow may last from one 
to six days, be very slight or profuse. It usually is not attended 
with symptoms, but if profuse may produce evident malaise in the 
child. It was a prominent symptom in one case of cerebral hemor- 
rhage following the forceps operation. See Obstetrics for Nurses. 



CONDUCT OF THE PUERPERIUM. 

Immediately after labor the patient receives a thorough washing 
of the genitals and parts that have been soiled with blood. Use 
I-2000 HgClo for this. A vaginal injection in normal cases is never 
necessary. 

I do not believe a douche can disinfect an infected parturient 
canal and use it only before passing the hand through the^ vagina into 
the uterus when necessary in such cases. In ordinary cases I mop 
the vagina thoroughly with cotton soaked in i% lysol before operat- 
ing. If there is post-partum hemorrhage may have to give a hot 
vaginal or uterine douche. 

The sheets are removed, the night dress, if soiled, also, clean dry 
ones are put on. The patient must not sit up for any of these pro- 
cedures, and in turning her to the side, etc., a hand must be on the 
uterus, assured of its contraction (danger of air embolism). 

There is a bloody oozing from the vulva for several hours after 
labor, and this requires a frequent change of napkins. The napkin 
consists of a piece of ordinary absorbent cotton wrapped in a piece 
of gauze, sterile or bichloride. 

The nurse must watch the patient carefully for the first hours 
after labor. (The doctor ought to stay at least an hour after the 
placenta is delivered.) 

As soon as possible the room is gotten to rights and the patient 
is given a chance to get her much needed rest. After her bed is 
fixed she is warmly covered up, lies on her back and generally goes 
to sleep. Every 20 or 30 minutes the nurse feels her pulse and slips 
her hand on to the uterus to feel if it is hard. If after 2 or 2^ 
hours there is no tendency to hemorrhage, the patient may be consid- 
ered safe from this accident. 

The nurse now attends to the child, which till now has been 
wrapped up in the woolen receiver and is kept in a warm place. The 
majority of doctors allow the binder to be put on, and the nurse 
herself generally puts it on unless told otherwise. She believes that 
it conduces to a good ''form" to put on a tight binder. There is no 
doubt that supporting the abdominal walls during the puerperium 
does help to prevent the occurrence of pendulous abdomen, but it is 
not necessary to bind the belly so tightly as is the custom. For the 
first 12 hours I forbid the use of a tight binder. Put on loosely 
enough so that you can piit the hand under it to feel the uterus. It 
will remove the empty feeling and the tendency to syncope. If there 



238 NOTES ON OBSTETRICS— JUNIOR CLASS. 

is a tendency to faintness from the sudden emptying- of the abdomen 
put a sand bag (warm) on the abdomen. 

After 12 hours the patient may be bound up moderately tight 
and this should be kept up for three meeks after patient is out of bed. 

Antisepsis During the Puerperium. 

This is every whit as important as during labor. Many cases 
have been successfully carried through hard labors, but have been 
infected late in the puerperium. 

The nurse is generally responsible for late infections, but the doc- 
tor is, too, if he should make local examinations, or come to the puer- 
pera after attending diphtheria cases, etc. 

Before touching the patient or touching anything that comes in 
contact with the genitals the nurse must wash her hands according 
to the directions. 

Every four to six hours, the patient must have the genitals 
dressed. A sterilized bed pan is placed under her, and the solution is 
poured over the parts from a pitcher, or from the irrigator, 1-2000 
HgCL is used. The fingers of the other hand gently separate- the 
labia and allow as much of the fluid as will run into the vagina. The 
excess is dried off with a sterilized towel. 

If there are sutures in the perineum, the limbs are not separated 
so far. No direct wiping of the vulva is to be allowed, especially if 
there are sutures. After every urination and bowel movement the 
same process must be repeated. No other local treatment is made. 
No douches in normal cases. The patient must be instructed not to 
put her hands down to the parts, or to touch her nipples with her 
hands. 

After each washing a new pad is put on, the old one burned. The 
Hartman wood wool pads are good. 

The hands are not the only sources of infection. Unclean bed 
pads, infected bed clothes may come in direct contact with the vulva. 
These are especially dangerous if there is a perineal tear. Internal 
examinations are not made in normal cases. You must diagnose 
the condition of things from the general symptoms and the external 
findings. Examine only under the strictest indications and with 
extra carefulness. Continue the vulvar washings for 10 days. They 
need then be made morning and evening only unless there are sutures 
in the perineum. 

Diet. 

An important subject. Great changes from olden times. For- 
merly custom to give puerpera watery soups, for the first week, 
allowing solid food only with great reserve. Now a much more 
generous diet allowed. 

No harm is done if the patient eats well during her lying-in. Of 



I 



NOTES ON OBSTETRICS— JUNIOR CLASS. 239 

course she should not continue as she has, since anybody put into 
bed suddenly ought to have a restricted diet. 

Experience has proved that v^omen with a fuller diet recuperate 
more rapidly, the child grows better, lactation being favored. After 
labor a glass of hot milk, or if patient is not made wakeful by it, 
coffee, or hot malted milk. 

For the first 24 hours patient wants fluid and let her have it. In 
the morning give her milk, which is not to be gulped down. At 10 
a. m. a fine broth with a cracker in it. At noon a strained gruel of 
some kind. At 3 p. m. coffee with milk and cream. Evening, a 
broth with some farinaceous body to it. If she wishes cold drinks, 
a ''milk shake," an egg lemonade, or cream lemonade in small 
amounts is allowable. Water, not too cold, ad lib. If the patient 
has lost a great deal of blood, give fluids freely, but see that you do 
not overload the stomach, as patient vomits easily. The second day 
patient may have strained gruel with thin toast in the morning. A 
soft egg with old bread at noon. Chocolate in the afternoon. Soft 
eggs or poached egg on toast in the evening. The next day at noon, 
a piece of tenderloin steak, not too well done. Patient may have as 
many as three eggs daily. Milk toast made from old bread in the 
evening. The really fluid diet need only be enforced for the first 
day. No solid fruits to be eaten. Juice of orange, orangeade, lem- 
onade, soda water, ice cream, are all allowable, if the patient be used 
to them, small quantities. It is said that beer increases the flow of 
milk (?). Said also of oysters. Milk may be given in as large 
amounts as the patient will take. 

After the fourth day patient may have rice or farina. Vegetables 
well cooked may be allowed after the fifth day. Fried stuffs are not 
to be given for two weeks, but broiled steak is allowed after the 
fourth day. In general the diet for the first week must be soft, 
easily digestible and leave very httle waste. For many practical 
points and details see book. Obstetrics for Nurses, by the author. 

Attention to the Bladder. 

This should require the physician's and nurse's careful attention. 

Immediately after labor it may fill rapidly, and may prevent the 
placenta from being expelled promptly. 

The bladder should be emptied inside of the first 12 hours. If 
the woman cannot do this herself there are numerous little aids: ist, 
let the water run in the room, or next room. Do not let her know 
the reason of this. 2nd, put her on a warm bed pan, with some 
steaming water in it and leave her to herself. 3rd, let a warm solu- 
tion of sterile water run over the parts 01 put a moist compress over 
the bladder. The fluid running over the parts imitates the flow of 
urine. 4th, let her smelt salts. If a very nervous woman try to get 
her attention away from the act. 5th, warm fomentations. 6th, may 



•240 NOTES ON OBSTETRICS— JUNIOR CLASS. 

allow her to assume the half-sitting posture. 7th, the catheter. Be- 
fore having resorted to this, one must have tried the others and 
waited fully 12 hours, unless the bladder is full and causes distress. 
A full bladder may give rise to post partum hemorrhage. Do not 
use the catheter except in the most obstinate cases. The patient is 
so very likely to get a cystitis. If a woman has to be catheterized 
daily for over four days, a cystitis w^ill almost invariably result. The 
nurse deserves the highest praise if she can prevent this. 

Before passing the catheter, the vulva and especially the urethral 
orifice must be washed thoroughly with HgCU, 1-2000, or 1% 
Lysol. The hands carefully sterilized, the catheter boiled and wet 
with 1-2000 HgClo or 1% Lysol, is carried directly into the urethra, 
almays by sight. If the first pass should bring it into the vagina, 
it must be boiled again or another catheter used. 

If vaseline is used to lubricate, the vaselin(^ must be boiled. Do 
not allow the nurse to use the catheter unless she knows how. Try 
to avoid the use of the instrument, because the patient may have per- 
manent bladder trouble from it. A certain number of women will 
pass urine if it be "suggested" to them. Urination ought to be three 
times daily. Do not pass the catheter this often. Twice daily if 
absolutely necessary. 

Attention to the Bowels. 

Custom, and it was a good one, gives one ounce Ol. Ricini on the 
third day. Now better to give it on the second day. Favors the 
secretion of milk and moves the bowels. Other cathartics, especially 
the salines, diminish the amount of milk. Thus, if patient not to 
nurse, prefer the salines. The oil may be given in orange juice. 
Or may be given in German Weissbier. Or may be taken on top 
of some sherry wine. There are many ways. Soft capsules. One 
bowel movement every day is necessary. Patient must not sit up for 
the bowel movement. After each bowel movement wash the vulva 
with 1-2000 HgClo. An enema daily may be necessary, also cascara. 

In cases of ordinary perineal tears no change from the above. If 
a deep or a complete tear, special attention must be given. If it be 
deemed inadvisable to give the cathartic, a glycerine suppository may 
be used, or a soap and water enema. If the patient has signs of a pel- 
vic peritonitis it is not best to give cathartics more than the first day 
of attack. 

Attention to the Breasts. 

During pregnancy the care of the breasts must begin. A retracted 
nipple may be somewhat developed. Little good is to be expected 
from hardening with alcohol. More rational is the anointing with 
cocoa butter after washing with water and soap. 

Immediately after labor the nurse should w^ash the nipples and 



^NOTES ON OBSTETRICS— JUNIOR CLASS. 241 

surrounding skin with soap and water, then with 1/2000 HgCl2, once 
only ; thereafter, boric acid sokition. Now anoint them with albolene 
or cocoa butter, cover with a piece of dry sterile or borated gauze. 
In attending to this the hands must be sterilized, and throughout 
no manipulation of the breasts may be made without first carefully 
cleaning the hands. This applies also to the patient, who may have 
gotten lochial secretion on her fingers. 

The breasts should be supported with a moderately tight binder. 
If they are very large and heavy, a towel, rolled up, may be placed 
under each, beneath the binder, at the sides of the chest. This keeps 
the breasts from sagging down and relieves the heavy feeling. Or, 
two pillows laid alongside the body may support the breasts. If the 
milk should shoot into the breasts too strongly, the binder may be 
made with counter pressure, preventing to a slight degree the enlarge- 
ment of the glands. Ice bags are supplied and a saline laxative 
given. After each nursing the nipple is washed with saturated 
solution of boric acid^ then covered with the sterile or borated gauze, 
which is changed frequently, should it become wet. Three times 
daily the nipple is oiled with cocoa butter. I have found this a 
good preventative of cracks and fissures. Albolene may also be 
used for this. If there are fissures, use 2% boro-glycerine very fre- 
quently on the nipples. AgN03, 2%, is also used. The object of 
these precautions is the prevention of mastitis. This is due to in- 
fection of the breasts and is in the highest degree preventable. Ow- 
nig to the continual use of the breast the atria of infection are open 
for a greater period, and infection is not so efifectually prevented as 
in the genitals. Estimated that 6% of women have mastitis, but in 
private practice this is too high. The cracks and fissures are the 
usual atria of the infection. They can be prevented by this treat- 
ment, and if present may be kept aseptic. Aside from the danger of 
infection, these cracks are very painful and may make nursing im- 
possible. Try the boro-glycerine, then alterate with paintings of 
Comp. tr. Benzoin. If they will not heal with this, touch them with 
a little strong (10%) AgNo3, touching the crack only, and have the 
patient wear Wansb rough's lead nipple shields constantly between 
nursings. 

Nursing the Baby. 

Every mother, unless sick, should nurse her baby. No excuse 
other than physical inability, e. g., tuberculosis, etc., disease of the 
breasts, should be allowed. Better for mother as well as the baby 
that its own mother nurse it. In the absence of the mother's milk 
a wet nurse should be provided. It is said that no man became 
great if he was brought 43p on a bottle. No substitute for mother's 
milk has vet been found. 



242 NOTES ON OBSTETRICS— JUNIOR CLASS. 

The question of nursing is an important one. Put the baby to 
the breast as soon as the mother has rested a Httle. This is usually 
about 12 hours after labor. Reason is, that even though there is very 
little milk, the baby learns the habit of nursing, the nipple is de- 
veloped, the breasts are stimulated to secretion earlier, and the child 
gets what little fluid there is. The baby is put to the breast every 
four hours till the milk comes, then every two to three hours. Teach 
the infant good habits early. Put him to the breast at certain hours 
by the clock. He soon learns to wake up at those hours. A child 
can learn a bad habit in the first day of his life, and his mental 
training is begun immediately he is born. It is important to know 
if the child has gotten enough at each nursing. With a little expe- 
rience the mother can tell by the aspect of the child. It looks and 
acts satisfied. If in doubt, you can weigh the child before and after 
the nursing. 

Table. 

In the first day, four or five nursings, 5 grams each. 

In the second day, six to eight nursings, 15 grams each. 

In the third to eighth day, eight nursings, 25 to 60 grams each. 

In the eighth to twentieth day, eight nursings, 60 to 90 grams 
each. 

In the second month, six nursings, ICK) to 120 grams each. 

In the fourth to ninth month, five to six nursings, 160 grams or 
more each. 

During the day put the baby to the breast every two and one-half 
to three hours. After 9 p. m. let the baby sleep as long as it will. 
Before nursing it, should it awake, see that the diaper is dry, or let 
it cry awhile, since it may not be hungry, but will go to sleep again. 
After awhile it becomes accustomed to be nursed in the day and to 
sleep all night or with one awaking. This can almost always be 
accomplished in three weeks. The child should not be disturbed be- 
tween times for any other reason than attention to itself. 

Contra-Indications to Nursing by the Mother. 

I. General Diseases. Tuberculosis. Experience teaches that the 
disease takes rapid growth, that a previously latent tuberculosis may 
now become active. 

Severe Anemia. Not necessarily a contra-indication. With good 
and full diet, patient recovers rapidly and may nurse. 

Syphilis. If the child be healthy and mother diseased. If the 
child is infected during its passage through the vagina, no objection 
to nursing. 

II. Malformations of the Breasts, (i) Sometimes the nipples 
may be so deformed that the baby cannot grasp them. By the use of 



NOTES ON OBSTETRICS— JUNIOR CLASS. 243 

a nipple shield this may be removed. Operations on the nipples to 
make them suitable for nursing have not been successful. (2) In 
mastitis nursing must be stopped, this almost always cutting the 
inflammation short. (3) Cracks (only a few days till they heal). 

III. Diseases of the Child, (i) Malformations, e. g., hare lip. 
Or the fetus may be too weak, i. e., premature. 

Syphilis. If the mother is infected, with the child, no objection; 
and if the child alone is infected experience has shown that the 
mother acquires certain immunity against infection. Not allowable 
to put a syphilitic child to a healthy wet nurse. Widerhofer says, 
however, that they do not always get syphilis. 

Patient's Toilet. 

Every morning she receives a general sponge bath, warm water 
with perhaps a little cologne water in it to make it more refreshing. 
This should be given when the room is warm and partly under a 
sheet. If she is restless in the evening, repeat it, as she will sleep 
better afterwards. It is advisable also to change the night dress 
before the patient goes to sleep. She should keep her hands clean 
and aseptic, should not get them infected with lochia, as she may 
carry the infection to the baby's cord or mouth, or to her own breasts, 
and cause mastitis. 

The room should be large, well ventilated, light, so that you can 
see the patient and the patient receive some sun. May be darkened 
when patient is to sleep. 

The Pulse and Temperature. 

The nurse should take the pulse and temperature, and respira- 
tion, morning and evening at least. About 8 :30 a. m. and 7 in the 
evening. If some severe operation has been done temperature taken 
T. I. D., 7 a. m., 4 p. m. and 9 p. m., or every four hours, as after 
laparotomy. The pulse may be counted frequently during the day 
and the temperature taken should it show any marked increase. 

Some patients are very nervous about their temperature, since 
the knowledge of puerperal fever is widespread among the better 
classes. Little ostentation, therefore. The pulse is of more impor- 
tance than the temperature in the prognosis of diseases and of the 
puerperium, but the temperature gives more certain information as 
to disease, being not so mobile as the pulse. A rise above 100 de- 
grees F. is pathological. The pulse should not rise above 100 to the 
minute. Even this rate is somewhat suspicious. 

The same rules about the pulse obtain in obstetrics as in general 
medicine. One is often able to tell from the simple feeling of the 
pulse whether the patient is well or not. 

The patient should lie on the back for 24 hours after labor, espe- 



244 NOTES ON OBSTETRICS— JUNIOR CLASS. 

cially if an operative delivery, and then may turn to one or the other 
side, but always slowly and with the legs well together. She should 
not sit up, except in rare cases to aid urination, and then not bolt 
upright, but half way, bolstered up with pillows. 

After the eighth day, if everything has gone well, she may sit 
bolt upright in bed to her meals. On the twelfth day she may get 
to the sofa. She must stay in her room for two weeks and may be 
allowed to go downstairs toward the end of the third week. Much 
will depend on the condition of the patient, the progress of involu- 
tion, the condition of the lochia. If bloody, she should not get up so 
soon. Not hard to keep above rules and the patients do so much 
better when they are observed that you must come as close to them 
as possible. 

The Doctor's Visit. He should have a certain method to go 
through, so as not to forget anything. 

There are 12 points that he must learn at each visit : 

I. Countenance. 2. Tongue. 3. Bowels. 4. Urination. 5. 
Sleep. 6. Diet. 7. Temperature, morning and evening. 8. Pulse, 
morning and evening. 9. Breasts. 10. Uterus — height, size, ten- 
derness. II. Genitals. 12. Lochia. It is usually not difficult to get 
the information necessary. A visit is usually made within 12 hours 
after labor. Subsequent visits are generally a personal matter with 
each physician. Some physicians make visits on the first, second, 
fourth, sixth and tenth days ; others, first, fourth and tenth. It is 
well to make daily visits to your puerpera and certainly if a hard 
operation has been done. Then every third day. 

ATTENTION TO THE BABY. 

I. Bath. Old and fixed custom to bathe the baby every day. 
There are many objections to this, e. g. : 

1. Baby gets cold and blue, unless bath very carefully given. 

2. Danger of infection of the cord, eyes, etc. 

3. Various eruptions on the skin due to soap and water. 
Better to oil the baby for the first week or until the navel is healed. 

Simple olive oil or lard applied with the hand, and wiped of¥ with a 
soft linen towel, daily. Hands and face may be washed in the even- 
ing with soap and water. 

Dressing the Cord. 

Binder changed every day or as often as it becomes soiled. The 
dressing of the cord is not disturbed unless soiled, when it is soaked 
ofif in 1-2000 HgClo, a new dressing of boric gauze applied, dry. 
Should it show any signs of moist gangrene, a dressing of alcohol, 
50%, is put on for eight hours, then removed and the cord dressed 



NOTES ON OBSTETRICS— JUNIOR CLASS. 245 

as before. If still moist the next day^ dress with sterilized starch. 
After the cord drops ofif the wound is dressed as usual. 

Care of the Eyes. 

Every morning the lids are washed with saturated boric solution 
and a few drops allowed to run into the eyes, from a bottle, not fin- 
gers. If baths are used, nurse to be instructed not to allow any 
fluid to get into the eyes. Greatest gentleness to be exercised. 

Attention to the Bladder. 

Urine is almost always passed in the first 12 hours. If not, 
examine to see if there is any congenital deformity of the parts. If 
the 'baby does not urinate it is generally due to some cause other 
than obstruction. Either the child has gotten too little fluid or it has 
some form of febrile affection, usually sepsis. A tight foreskin 
almost never the cause. If the baby does not urinate, a warm bath 
may be given. An application of warm compresses to the pubis. 
Only in the rarest cases have resort to the catheter. 

Attention to the Bozvels. 

Unless there is some deformity of the anus, no attention neces- 
sary. The meconium is generally discharged in the first 12 hours, 
but may not come for two days. A few drops of castor oil (gtt x) 
are sufficient. The parts around the anus do not get excoriated if 
the mother nurses the child, but with artificial feeding it is almost 
the rule. 

Excoriation is prevented by absolute cleanliness, frequent changes 
of the diaper. Use of ironed diapers free from dried urine, strong 
soaps, alkalies, oiling the parts, then gently drying them without fric- 
tion, and moderate use of a powder of stearate of zinc. 

The baby's mouth must be washed every morning with boric acid 
solution. Must be done gently, since rough rubbing may rub the 
epithelium off the gums, especially at the posterior parts, where the 
pterygoid processes are, and cause superficial ulcers, Bednar's Aph- 
thae. 

The clothing of the infant should be simple, warm and should 
allow free motion to the limbs and chest. 

Baby's temperature to be taken morning and evening, and accu- 
rate record to be kept just as of the mother. 



SENIOR NOTES. 



SENIOR NOTES. 



THE PATHOLOGY OF PREGNANCY. 

It is not surprising that a function which causes such marked 
general and local changes as conception and gestation, should not 
be completed without the production of conditions that might be 
considered pathological. Pregnancy does not confer immunity to 
any disease, rather it makes the women susceptible to certain general 
diseases and almost always aggravates existing general, and especi- 
ally local, affections. Only seldom do we hear that patients feel 
better during pregnancy than at other times, and not a few suffer 
great discomfort or even serious alteration of function. 

The diseases of pregnancy may be divided into : 
1st. Those of the mother; 
2nd. Those of the ovum. 

Of diseases of the mother w^e have, first, general diseases, and, 
second, local diseases (those of the uterus and decidua). 

Of general diseases we have, first, those which are entirely acci- 
dental to pregnancy, e. g., smallpox, grippe, syphilis, etc. ; second, 
those which are due to an exaggeration of the conditions induced 
by pregnancy, e. g., hyperemesis gravidarum, kidney of pregnancy — 
the various anemias, etc. 

Of diseases purely local there are local inflammations, of which 
endometritis is the most common. 

The diseases of the ovum are divided into : — 

1. Diseases of the Fetal Envelopes, Chorion, Amnion, Placenta. 

2. Diseases of the Fetus itself, e. g., syphilis, monsters, etc. 
After this should be considered the development of the ovum in 

abnormal places, i. e.. Ectopic Gestation, and finally the interruption 
of pregnancy before the natural termination, i. e., Abortion. 

The general diseases incident to pregnancy show themselves most 
commonly in the nervous system, the kidneys and the blood. The 
nervous system of a pregnant woman is like that of a child — hyper- 
excitable, and external irritants are more keenly felt. All the func- 
tions of a pregnant woman are in exaggerated action, and failure of 
any one has more serious consequences than usual. 

Of all diseases the expression of aggravated normal conditions, 
hyperemesis gravidarum claims first consideration. 



250 NOTES ON OBSTETRICS— SENIOR CLASS. 

HYPEREMESIS GRAVmARUM. 

Nausea and vomiting to a more or less degree occurs in 60% of 
pregnant women and are considered normal. They may be so marked 
as to become serious and deserve the appellation "pernicious," lead- 
ing not seldom to abortion or death, or both. It is difficult with a 
given case to tell when the vomiting passes from the normal to the 
pathological. Other names for .the disease are, uncontrollable vom- 
iting, pernicious vomiting, incoercible vomiting of pregnancy. 

Paul of Aegina observed the disease, but Mauriceau, in the i8th 
century, called attention to the danger of the affection. Simons, in 
181 3, was the first to interrupt pregnancy, and with success. Paul 
Dubois, in 1852, before the French Academy of Medicine, presented 
a deep thesis on the subject, which is still classical. 

It is said that Charlotte Bronte died of this affection. Multiparae 
suffer twice as often as primiparae from hyperemesis, a noteworthy 
fact because the ordinary vomiting is much more frequent in the 
latter. 

The disease usually begins in the second month, more rarely in 
the fourth month, but may appear in the sixth month. Seldom after 
this. If later suspect Nephritis. It lasts from six weeks to three 
months, usually, but may take such a violent course as to be fatal 
in two weeks. It may also intermit for a few weeks, then recur, 
growing better, then worse. 

Symptoms. 

Begins insidiously ; a slight nausea and vomiting in the morning, 
gradually becoming more frequent during the day. One of the first 
signs of the nausea and vomiting having become pathological is the 
loss of appetite. Vomits everything — nausea almost constant, and 
there is a loathing for food, vomiting and retching at the sight or 
mention of it. Or a change in the position of the person w\\\ start 
the vomiting. Continues at night and the patient has no sleep. 

Hiccough sets in and may be a troublesome symptom. Pyrosis 
is sometimes marked, retching causes great weakness and fatigue. 
Patient becomes restless, irritable, because she loses her sleep. Great 
thirst. General prostration. 

Vomit first composed of undigested food, mucus and a little bile ; 
afterward mucus and bile; finally it may become bloody or "coffee 
grounds." 

The blood comes from the stomach, or from the mouth or 
pharynx. As the disease progresses the pharynx becomes red, in- 
flamed, an important symptom, significant for treatment. Ptyalism 
has been noted. Constipation is marked, but rarely there is diarrhea, 
former preferable. Patient complains of pain in the epigastrium, 
boring in character and constant. Tenderness is found on palpation. 



NOTES ON OBSTETRICS—SENIOR CLASS. 261 

The urine is diminished, high colored, may have albumin and casts 
and diazo-reaction, especially as the disease progresses. Evidences 
of cloudy swelling and degeneration of the kidneys. The tempera- 
ture rises in the bad cases, or may remain subnormal till shortly be- 
fore the end. The pulse quickens, may be to 120, and loses strength. 
The skin is hot and dry, somewhat scaly, resiliency lost, of a waxy 
color, somewhat gray and sometimes jaundiced. Extremities usually 
cold, eyes hollow. Emaciation is variable, most often is marked, 
but the patient may die from exhaustion or toxemia without losing 
all the panniculus adiposus. In some cases the loss of flesh is so pro- 
nounced that the patient has a scaphoid abdomen, which allows one 
to trace the course of aorta and its bifurcation. A case is recorded 
where 45 pounds were lost in six weeks — over a pound a day. 

If the disease progresses, the symptoms aggravate. The tongue is 
dry, hot or cracked, the gums spongy or bleeding, the breath is 
offensive, sordes appears. The patient is somnolent, at times deliri- 
ous. The pulse goes to 150-170. Fever of a continuous type and 
the emaciation continues and the patient may die under the symp- 
toms of uncontrollable vomiting and acute starvation. 

Toward the last the vomiting may cease. Remissions in the dis- 
ease occasionally occur, the interval being weeks or days. 

Dubois divides the symptoms into three stages, but the boun- 
daries are not clearly definable. The fetus is usually alive during 
all this disturbance till shortly before the death of the patient. If 
the disease is due to toxemia, the cause may kill it sooner, when 
the vomiting may cease and abortion occurs. Or at the height of 
the symptoms abortion occurs, when the patient may get well, but 
sometimes the spontaneous interruption of the. pregnancy does not 
save her, and the same may be said of artificial abortion, though 
a favorable result is common. 

Again, suddenly, without definable cause, the woman may de- 
mand food, retain it and proceed to recovery. This has been noted 
at the time of quickening. These cases show the psychic influences 
in the disease. The vomiting may be absent, a constant and de- 
pressing nausea taking its place. 

Causation. 

There are four classes of cases : 

I. Those in which the vomiting is a reflex from the genitalia. 
II. The vomiting is due to disease of the stomach or some ab- 
dominal disorder aggravated by pregnancy. 

III. Where the nervous system is at fault. 

IV. Where a toxemia is the underlying cause. 

I. There is no doubt of the reflex excitability being increased 
during pregnancy. This can be demonstrated by examination of 



252 NOTES ON OBSTETRICS—SENIOR CLASS. 

the cutaneous and tendon reflexes. The close connections between 
the genitaha and the stomach, per the sympathetic and vagus, make 
reflexes in this arc easy. The tendency to vomit when pressure is 
made on the ovary is a common example. The genital tract can 
furnish a host of irritants, so that various conditions may cause this 
reflex. 

(a) Oldest theory. Excessive distension of the uterus more 

rapidly than it can bear, especially if the wall be hard- 
ened, e. g., metritis, or if the stretching is abnormal, 
e. g., hydramnion, twins. 

(b) Theory of Grailly Hewitt. Displacement of the uterus, 

especially ante and retroflexions, especially if the 
fundus is caught under the pubis or sacrum. Reflex 
is caused by the pinching of the nerves, or the uterus 
not being able to expand. Of course this would be 
enhanced by pathological conditions of the uterus and 
adnexae. This cause is not rare — and it may be 
proven by the effect of treatment, as the lifting of the 
uterus up and holding it in place with an air pessary 
stops the nausea and vomiting. 

(c) Bennett's theory. Chronic cervicitis, with or without 

erosions. Local treatment sometimes curative. 

(d) Schroeder & Veit. Chronic endometritis. Many other 

pathological conditions of the genitals may be ad- 
duced as causes and several may cooperate. 

IL That class of cases where no lesion of the genitals is demon- 
strable, but a pathological condition may be found in the stomach or 
neighboring organs. Such causes are gastric ulcer, gastritis, carci- 
noma, tubercular peritonitis, etc. Pregnancy coming on one of 
these conditions is not unlikely to make the vomiting pernicious. 

in. When these two classes are not causative the nervous sys- 
tem is interrogated. Ahlfeld (Lehrbuch der Geb., 1900) says the 
vomiting is due to circulatory disturbances in the brain similar to 
seasickness. 

Hysteria is not a rare cause of vomiting and it may be fatal. It 
is in these cases that we see magical effects of treatment through 
suggestion. A ''nervous" tendency will aggravate any existing 
cause. 

Brain lesions, tubercle, other tumors and meningitis have been 
found. Polyneuritis, especially of the pneumogastric, has been found 
at autopsy, but this is perhaps the effect, not the cause, or perhaps 
an effect of a common cause. 

IV. Toxemia. Recently a poisoning of the blood has been held 
accountable for numerous pathological symptom complexes. Bouch- 
ard believed he proved the toxicity of the blood and the theory has 



NOTES OX OBSTETRICS—SENIOR CLASS. 253 

been useful in explaining many of the complications of the puer- 
peral state. Recently Bouchard's conclusions have been called into 
question b}- German experimenters. This will be considered later. 

Alan}- cases of vomiting in pregnane}- can be best explained on 
the assumption of a toxemia ; appropriate treatment relieves them 
proiiiptlv. (Lindeman, c. f. allg. Path. u. Path. Anat., 1893, ^^^' 3 
Nr. 15.) 

Uremia may cause vomiting, though it is more common later in 
gestation. 

Diagnosis. 

This is more difficult than appears on first thought, as it con- 
sists : 

(a) In the diagnosis of pregnancy, which is not so easy in the 
first trimester, when the vomiting almost always begins ; (b) The 
diagnosis of the adjuvant cause of the vomiting; (c) The determina- 
tion of what stage the patient is in, i. e., the gravity of the case. 

The diagnosis of the cause is not always possible. Malpositions 
of the uterus, disease of the cervix, neighboring organs almost always 
to be discovered, but endometritis, etc., not. Diseases of the stom- 
ach may be affirmed^ but nervous and hysterical vomiting are hard 
to be separated. Toxemia is easier. Pay attention to the four 
classes of causes, and examine the patient from head to foot care- 
fully, also blood and urine. Make the premises broad, take sufficient 
time and you will almost always make a working diagnosis. 

The three stages of the disease are as follows : 

1. A'omiting after food whenever taken. 

2. Vomiting continuous irrespective of food in the stomach, fever 
begins, emaciation, pulse rises, patient very sick. 

3. Vomit bloody, patient usually prostrated, continuous fever, 
extreme emaciation, jaundice, delirium, usually death. The diazo- 
reaction in the urine said to indicate a severe form of emesis. 

Prognosis. 

The outlook is serious, the mortality ranging from 20% to 50%. 
The disease may terminate : 

1. Recovery without abortion, and this, too, when the symptoms 
have been very severe ; change may be sudden or may be gradual. 

2. Recovery after abortion, artificial or spontaneous. 

3. Death before abortion (or during abortion). 

4. Death after abortion, spontaneous or artificial. 

If due simply to pregnancy, and not to a pathological condition 
existing before pregnancy, the prognosis is good, few^ fatal cases be- 
ing reported. Prognosis bad if due to some organic lesion of the 
stomach, kidneys or brain which is aggravated by pregnancy. Pa- 



254 NOTES ON OBSTETRICS—SENIOR CLASS. 

tient may die from rupture of the bowel from constant retching; 
from starvation, in delirium ; from the shock of an abortion. Patient 
may die of acute exhaustion after apparent improvement. Hard 
to give per centum, because men's ideas of uncontrollable vomiting 
differ. 

Treatment. 

Recognize the cause, elimination of which cures the patient. 
Since this is not always possible, a certain treatment may be laid 
down to be followed in all cases : I. Hygienic. H. Medical. HI. 
Gynecological. IV. Obstetric. 

Hygienic — Usually you will treat the case as a mild one for 
awhile, but when you have judged it pathologic, place the patient on 
her back, in bed. 

Isolation — Alone with the nurse. Darken the room. Vomiting 
may be ocular in origin. Laxative if necessary or an enema. Direct 
patient's attention from herself. Therefore rest in the horizontal po- 
sition. Isolation, regulate the bowels. 

Diet — In pregnant women the appetite is capricious. Longings 
for things formerly indigestible. If the desired food is digestible, 
let her have it. Dr. Meigs waked patient up early — gave coffee and 
crackers and then patient remained in bed an hour. Small amount 
of quickly digestible food, e. g., peptonized milk, peptonized meat 
juice, bouillion and cracker, soft boiled egg, juice of clam, oyster 
soup, egg lemonade or iced milk. Cham.pagne sometimes settles the 
stomach. Given in the horizontal position, they sometimes may be 
retained, or the stomach tube may be tried. 

If vomiting is constant, give the stomach a rest — complete. Som- 
atose may be given. Rectal alimentation ; peptones — fluids ; dextrin ; 
peptonized milk — oz. vi. — at each injection, and not oftener than 
eight or six hours. Diarrhea may increase the trouble and stops the 
treatment. 

Suggestion — Since the vomiting is so often a neurosis, or is on 
a neurotic basis, suggestion may be of value. Many of the means 
here recommended act in this way and the physician is justified in 
using its full power. 

Medical — No specific for this disease. Host of remedies used 
with apparent success and dismal failure, which shows that there is 
no specific and that cases terminate frequently spontaneously. Rem- 
edies of four classes : 

I. Local anesthetics. Hydrochl. of Cocaine, gr. yg in oz. i of 
water. Has little influence in the bad nausea and vomiting, but may 
help to retain some food for awhile. Menthol, gr. ^ to ^, in wa- 
ter. Volatile oils, peppermint, wintergreen. Cracked ice swallowed 
whole may relieve thirst. 



NOTES ON OBSTETRICS—SENIOR CLASS. 265 

2. Mechanical Drugs. Bismuth, Oxalate cerium, etc. Diges- 
tive ferments do not act as well as in the non-pregnant state. Claims 
made for Ingluvin. When gastritis or atonic dyspeptic symptoms 
appear, Tr. Nucis. Vomicae and Hcl, especially if alcoholic basis. 
Usually as the disease gets worse, drugs of more harm than good. 

3. Depresso-motors. Bromides, Chloral, Morphia, in order 
named, given in large doses by rectum — o ss of Na. ,Br. Chloral in 
egg water every eight hours. 

Morphine, gr. ^ hypo., once; effect is apparent but may increase 
the nausea. Give Atropia with it. In some cases of centric vomiting 
alcohol has a good effect. Dry Champagne, brandy. If it is retained 
may go on with other food. 

4. External remedies. Ether spray and pressure on the stomach. 
Warm flannel band around the stomach, tightly. Fly blister to epi- 
gastrium. Ice bag of Chapman to the spine (a long, cylindrical 
ice bag), or a blister to the fifth or sixth cervical spine. Electricity 
is of little use. 

Kaltenbach has warmly recommended washing out the stomach 
for Hyperemesis Gravidarum. In certain hysterical cases it does 
great good, and may in gastritis also. Certainly might be tried, un- 
less the patient is too weak, as it is depressing. 

5. Salt solution, y%, injected subcutaneously, is a valuable addi- 
tion to our means for meeting the loss of body fluids from the con- 
stant vomiting. A quart may be injected every day or several times 
a day. 

The extremities may be wrapped in wet towels, and inunctions 
of oil or lard used, some of these being absorbed. 
Gynecologic Treatment. — Examine carefully. 

1. Replace the retroposed or ante verted uterus and retain with a 
tampon or a balloon pessary. Replace in genu pectoral position. 
Mechanical irritation may cause abortion. 

Anteversion — the same treatment. This causes vomiting usually 
early in pregnancy. Lifting up the uterus will then stop the nausea 
and vomiting at once. The knee chest posture may be used as a 
routine procedure. 

2. Erosion or Ectropion of the Cervix. Bennett. 

In some cases no change can be seen, but it is routine to treat the 
cervix anyway, with a 10% AgNo3 solution. Bennett himself 
used carbolic acid and iodine. M. O. Jones introduced AgNo3, 
but Marion Sims improved the treatment. Now AgNo3 used en- 
tirely. 

Wash out the vagina with tepid water,. Ferguson speculum, pour 
oz. I of 10% AgNo3 solution. Let it stay until the mucous mem- 
brane is whitened. Don't repeat more than three times, at intervals 
of 48 hours. Rationale not fully understood in cases where no ap- 



256 NOTES ON OBSTETRICS— SENIOR CLASS. 

parent pathological change. It improves many cases, perhaps chem- 
ical action on the great cervical ganglion ; or it starts a reflex, or 
perhaps it is psychic. Apply the treatment faithfully. Cocaine 
locally not as good. 

3. Mechanical dilation of the cervix. Copeman's Method. 

In 1875 he saved a patient near death and has found that the 
majority it succeeded in bringing relief complete or partial. Index 
finger, or if there is no dilatation, Hegar's dilators. Don't go be- 
yond No. 12 in primiparae — in multiparae, No. 14. Rationale also 
obscure, may be nev^ reflexes. 

Owing to the danger of sepsis great precaution necessary and 
to the danger of abortion it is necessary to leave this till the last. 
If this does not succeed, abortion only remains. 

Similar to Copeman's method is packing the cervix with gauze. 
In some cases it will stop the emesis. Done likewise just before 
inducing abortion. 

4. Obstetric Treatment ■ — There is great difiference of opinion as 
to this operation. Germans are very conservative, but they don't 
have much of this disease. The larger one's experience grows the 
less inclined he is to abortion, which may be due to greater skill in 
treatment. Abortion will not always stop the vomiting if due to 
some other cause than pregnancy, and may not even do so if due to 
pregnancy alone. Cohnstein found abortion cured in only 40% of 
cases. Later statistics are better — 75% recoveries. 

Delicate question in diagnosis. Always consultation, ist, to 
verify your diagnosis. 2nd, to share responsibility. Two physicians 
draw up paper and with husband sign it — good to have in case of 
litigation. Avoid all secrecy. When shall you do it ? Very difficult 
to say. Always before the febrile state, before vomit is bloody, be- 
fore patient so weak that you fear she may die under operation. 
Pinard says after pulse has gone above 100 induce abortion. If 
there is a great loss of weight and a marked absence of panniculus 
adiposus, abortion. Best method is rapid dilatation and emptying of 
the uterus at one sitting. 

Hyperemesis is sometimes feigned so as to mislead the accou- 
cheur into performing an abortion. The patient will exaggerate 
and falsify statements of her symptoms. In all cases the objective 
signs only should be relied upon. 

The milder cases of vomiting have the same etiology and may be 
treated along the same lines as Hyperemesis. 

PTYALISM. 

Salivation is a rare complication of pregnancy. It is related to 
hyperemesis in that it is probably reflexly caused. Hippocrates 
noted it as one of the symptoms of pregnancy. It is to be distin- 



NOTES ON OBSTETRICS—SENIOR CLASS. 257 

guished from the "cotton-spitting" described by Dewees as one of 
the signs of pregnancy. 

Salivation usually occurs with the nausea and vomiting, but may 
occur alone. It begins usually in the second month and peases 
about the fifth, or at quickening, but it presents the same variations 
as the vomiting. 

It almost always ceases with parturition, but has continued for 
a few weeks. It usually occurs but once, but may appear in succes- 
sive pregnancies and may be absent in one and recur in the next. 

The flow varies in amount. Excessive quantities are reported, 
over two quarts a day. It usually lessens during the night, but ma5' 
continue unabated. The saliva is very watery, tasteless, odorless, 
limpid, not acid; it has no ptyalin. The patient cannot swallow it, 
it nauseates. 

The loss of this large amount of fluid, the absence of digestive 
power, and the loss of appetite, not seldom compromise the nutrition 
of the patient and a condition resembling that produced by incoercible 
vomiting has proven an indication for terminating the pregnancy in 
these cases. 

There are no changes in the mouth or gums. The salivary glands 
may be a little swollen, and there is sometimes a little gastric catarrh. 

The patients feel miserable, are always thirsty, have difficulty in 
talking, and the chin may be excoriated. They feel exhausted if the 
flow is marked. 

The causes being analogous to those of hyperemesis, the treat- 
ment is along similar lines. Toxemia has been emphasized as a 
cause. K I, Atropine, Pilocarpine are usually prescribed. The last 
is the best of the three — gr. i-^th, hypodermically, repeated five or 
six times in two or three days. The best results have been obtained 
with the bromides. Give NaBr., gr. xv t. i. d. by mouth or per 
rectum if it causes vomiting. Milk diet when toxemia is the cause. 

Salivation may occur in other conditions beside pregnancy, e. g.. 
cancer of uterus (Montgomery). 

GINGIVITIS. 

The slight tumefaction and hyperemia of the gums so often ob- 
served in pregnancy may be aggravated to a severe affection. Spon- 
giness of the gums, hemorrhages into them, even loosening and 
dropping of the teeth occur. There is no fetor, no salivation, and 
there is usually no pain in the parts, though mastication is difficult. 
There is no periodontitis. 

It begins about the fourth month, usually persists, is even aggra- 
vated after labor by lactation. The molars are usually not affected. 
It occurs oftener in multiparae, and in those who have bad teeth or 



•258 NOTES ON OBSTETRICS—SENIOR CLASS. 

care for the mouth poorly. Said to be clue to toxemia (Talbot, of 
Chicago). Occurs in other conditions than pregnancy; e. g., bad 
teeth, heart disease, etc. When giving mercury this condition is to 
be remembered. 

Treatment. 

Hygiene of the mouth. Care of the teeth. Wash of Pot. Chlo- 
rate. Tr. ]\lyrrh, dr. i ad oz. viii, water. 

THE ABDOMEN. 

Women often complain of digestive disturbances. These require 
the same treatment as in other conditions. Constipation causes most 
of them. Pain in the abdomen is a frequent symptom. It may be 
due to stretching of the walls — use albolene to help this. It may also 
be due to traction on the ribs by the recti muscles at their insertion. 
Support abdomen. 

A full colon (coprostasis) tympany, unusual distension (twins, 
etc.), pelvic congestion associated with large varicose veins, old 
peritonitic bands (e. g., from appendicitis, pelvic peritonitis, etc.), 
fibroids and other tumors, umbilical hernia, — these are some of the 
causes. Treatment, remove the cause. 

TOXEMIA. 

This term has obtained very general usage, though little is posi- 
tively known of the conditions it represents. It means that the blood 
contains toxines, of an alkaloidal nature, leucomaines or similar to 
these. These toxines are supposed to be the result of deficient gen- 
eral metabolism, or these same abnormal processes occurring in a spe- 
cial organ, as the liver, the kidneys, the thyroid ; again, the poisons 
are supposed to come from the fetus, the placenta, from abnormal 
chemism occurring here. As a result of the deficient action of some 
organs of the body, e. g., the liver, the kidneys, the thyroid, these 
poisons are retained in the body, or they are not sufficiently oxidized 
or changed so as to be rendered harmless. 

Such is the theory, and to explain why and how these changes 
originate we have other theories. It is believed that a neurasthenic 
basis exists for them ; that, "owing to a neurasthenic habit the or- 
ganism fails to adapt itself, both in the matter of circulation and of 
internal metabolism, to the changes of function incident to preg- 
nancy." 

The toxines may come from the intestinal canal, so-called ''in- 
testinal auto-intoxication." The liver does not arrest or elaborate 
the poisons as it should. 



NOTES ON OBSTETRICS—SENIOR CLASS. 259 

\^eit says the transportation and dissolution of syncitial elements 
of the placenta produce syncitio-toxins, which, if not properly met by 
anti-bodies in the patient's blood, act injuriously. 

Bacterial action is also said to cause the toxemia, — plausible but 
lacks proof. Albert says that endometritis, infective in origin, makes 
toxines which, absorbed, may cause toxemia, hyperemesis, even 
eclampsia. Some cases seem to favor belief in this theory. 

The name of Bouchard is most often associated with these 
studies on auto-intoxication, for he has done a great deal of work 
on the subject. He sought to prove a relation between the toxicity 
of the blood and the urine, deficient excretion showing increase in 
the former. Animals into which filtered urine of pregnant w^omen 
was injected had convulsions and died, autopsy showing the same 
conditions observed in the human. 

These conclusions have been questioned very recently, and our 
knowledge is, therefore, not positive, so that for the present the 
subject will be left as it is. For practice it is not unconditionally 
necessary to have every theory proven. The general applicability is 
sometimes proof itself. 

We recognize many groups of symptoms which can be satis- 
factorily explained by this theory of toxemia and treatment directed 
in appropriate lines is successful in relieving the conditions. 

Of the^symptoms, those referable to the nervous system are most 
prominent : headache, dizziness, neuritis, neuralgias, lassitude, some- 
times melancholia, aberrations of the special senses, of taste, of 
smell ; flashes before the eyes, seeing colored lights, amaurosis, 
somnolence, muscular twitchings, general pruritis, nausea, vomiting, 
salivation, pain in the stomach, thirst, constipation, sometimes alter- 
nating with diarrhea, colic, dyspnea, cardiac palpitation, pseudo- 
syncope, symptoms of a "forme frust" of Basedow's disease ; cough, 
without pulmonary findings, and asthmatic attacks ; diminished 
urination, burning during the act, — these are the main symptoms 
of the toxemia. Sometimes one, again another, set being in evi- 
dence. On examining such a patient, deficient action of the excre- 
tory organs will first be discovered. The skin is muddy, dry, in- 
elastic, and there is sometimes a distinct and characteristic odor. In 
bad cases there is a sub-icteric hue ; sometimes edema without al- 
buminuria. The tongue is coated, somewhat brown in the middle. 
The mouth is somewhat dry, the gums are red. Sometimes there is 
a gingivitis, fetor ex ore. The temperature may be elevated, but 
usually not much, and when there is fever it is irregular, atypical. 
The pulse is, in mild cases, not affected, the tension may be a little 
greater ; in severe cases, - the heart beats faster, and in the worst 
cases the heart is seriously affected — running 140 to 180 beats in 
the minute. The condition of the heart is analogous to that of the 



260 NOTES ON OBSTETRICS—SENIOR CLASS. 

adynamic fevers, — muscle degeneration ; first sound loses booming 
quality. Abdominally, there are few findings. The liver sometimes 
enlarged and tender, usually there is tympany, and the colon may 
be full. The urine is scanty, of variable specific gravity, often low, 
the color is deepened and cloudy ; usually there is no albumen, except 
in bad cases and late ; there may be sugar, an alimentary glycosuria, 
and perhaps peptone. The urea is diminished, often less than .3%, 
this forming a fairly reliable indication of the excretory activity of 
the kidneys and liver. Total solids, too, are often far below nor- 
mal. Leucin xanthin, indican, urobilin, have been found. Various 
organic (sometimes alkaloidal) substances, of narcotic, convulsive, 
hypothermic, cardiac poisonous qualities, are found in normal urine. 

Microscopically, in mild cases, there is nothing abnormal. Later, 
hyaline casts, then granular and epithelial casts and cells appear. 
If the poisonous matters continue to irritate the renal parenchyma, 
the signs of the kidney of pregnancy appear and in the last stages 
even those of acute nephritis. The "uro-toxic coefficient," i. e., the 
amount of urine necessary to kill i kilo of rabbit, is increased. 

The toxemia has a noxious effect on the fetus and the secundines. 
The child may be poisoned by the toxines which come to it per the 
placenta, and may die in utero, or be born weakly, or develop con- 
vulsions (in eclampsia of mother) ; or the hemorrhages which not 
seldom occur in the placenta may cause its death by asphyxia. Auto- 
intoxication, as a cause of placental hemorrhage, is being accepted. 

Prognosis — Depends on the cause. If the liver is at fault, treat- 
ment may be successful. If the kidney, likewise ; but if there is ante- 
cedent structural disease in either, guarded prognosis. 

Treatment — Prophylaxis. Get history of pregnant woman for 
hereditary liver, kidney or nervous disease, or some antecedent of 
this kind, e. g., icterus catarrhalis, neurasthenia, nephritis (scarla- 
tina, etc.). Examine the urine every three wrecks till the seventh 
mionth, then two weeks, but the signs of toxemia in the urine are 
usually later than the symptoms. Watch all pregnant women for 
the symptoms throughout pregnane}'. Keep all pregnant patients on 
a, diet of such that will not irritate the kidneys or liver; plenty of 
water, milk, buttermilk, all kinds of vegetables, cereals ; very little 
meat, not more than once a day ; few eggs, not more than one a day ; 
a little fish, not too freely of sugar, no fried starches (e. g., pies, 
thick pastry). 

Pay attention to the bowels and see that the patient passes suf- 
ficient amounts of urine. Wool clothing to keep skin normal. No 
circular body constriction, baths, fresh air, moderate exercise. 

When diagnosis of toxemia is made, put patient at once on a milk 
and water diet. Open bowels with salines (no potash salts); give 
patient daily warm baths followed by rest in bed, so that she sweats 



NOTES ON OBSTETRICS—SENIOR CLASS. 261 

freely. When symptoms subside, a more generous diet is to be 
tentatively resumed. 

In bad cases, put patient to bed, milk diet, daily hot packs, 
saline cathartics ; hypodermically Oiii .7% saline solution daily. 
Salt solution per rectum. If you fear that the toxemia is of a 
})re-eclamptic nature, give patient gr. x Chloral Hydrate t. i. d. ; 
may give more without danger, as toxemic cases stand twice as 
much as others. 

THE KIDNEYS IX PREGNANCY. 

It is generally admitted that during pregnancy the point of weak- 
est resistance is the kidneys. Owing to the greater demands made 
on it by the increased general metabolism, and the addition of a new 
source of excretory matters (the fetus), and the interference with 
its functions by the change in the intra-abdominal conditions, it is 
not at all surprising that its structure should suffer, that inflam- 
matory processes of a low grade be inaugurated, and that existing 
diseases of its structure be intensified. 

It is, therefore, apparent how necessary frequent and careful 
examinations of the urine are, but one should not expect to read the 
condition of the kidneys from the urine alone in all cases. The 
ancients noticed the occurrence of edemas in the pregnant woman. 
Albumen first shown in the urine by Blackball, in 1848; in 1849 
Blot showed that it is most often transitory, and defined the con- 
ditions in which it is found. 

Schroeder found 3 to 5% of pregnancy cases had an albuminuria, 
not much more than in the normal non-pregnant state. Greatest 
precautions were taken. Other authors show higher percentages, 
but this is due to admixture of mucus or discharges from the vagina. 

The importance of the albumen in the urine has been exaggerated. 
A physiological, at least, a harmless, albuminuria, can be said to 
exist when : 

(ist) It is slight in amount. 

(2nd) Absence of casts and renal epithelium. 

(3rd) No symptoms of involvement of the kidney or ureters, 

such as dropsy, uremic symptoms, hydronephrosis, 

anuria, etc. 

Fischer, of Prague, found in a large number of healthy preg- 
nancies, white blood corpuscles, and often red blood corpuscles, and 
ureter and bladder epithelium; even a few. hyaline casts, in the urine. 
In general, however, it .is better to regard all albumen in urine as 
suspicious, and watch the gravida carefully for symptoms of eclamp- 
sia, €tc. 



262 NOTES ON OBSTETRICS—SENIOR CLASS. 

CAUSATION OF THE RENAL DISTURBANCES. 

The majority of authors refute the idea of a special inflammation 
of the kidneys, due to the pregnancy, but say that morbid condi- 
tions of the pregnant woman can cause changes in the kidneys bor- 
dering on inflammation. 

Kraus, of Vienna, said that a low grade of inflammation would 
explain the condition best (this caused by some form of toxemia). 

The oldest viezv, that of Frerichs and Rosenstein, that there 
is a venous congestion due to the pressure of the pregnant uterus on 
the veins of the kidneys, or on the kidneys, impeding their cir- 
culation. 

Not generally admitted, because albuminuria may occur early 
before any such pressure possible, and, further, even at term the 
uterus does not press upon the kidneys. The pressure of the gravid 
uterus is but very little more than the intestinal mass. 

There' is no doubt as to the existence of a venous hyperemia, but 
this cause is obstruction to the venous circulation, because of the 
great increase in the intra-abdominal tension. In support of the lat- 
ter view, we can adduce the following : 

(i) Albuminuria, and renal disturbances in general, are more 
frequent in primiparae because of tense abdominal walls. 

(2) In great abdominal enlargement, from twins, hydramnion, 
pregnancy with tumors, etc., we find them more often t^ conversely, 
the absence of these symptoms make the occurrence of twins, etc., 
unlikely) . 

(3) In the non-gravid state, large abdominal tumors will some- 
times cause .albuminuria ; in these tumors, however, there may be 
pressure on the veins because their specific gravity is somewhat 
greater than that of the intestinal mass, and they are often ad- 
herent in the pelvis. 

(4) After the evacuation of the uterus symptoms usually disap- 
pear. 

Second theory, that of Halbertsma, that compression of the ure- 
ters by the gravid uterus causes stasis of urine. A slight pressure 
is enough, but this can occur only in the early months, and after the 
head has gotten into the pelvis late in pregnancy. Serves to explain 
a few cases possibly. It has been denied that the uterus can com- 
press the ureters. 

Third theory, that of Traube — Changes in the blood incident to 
pregnancy. Kidney is supplied with poor, watery blood, therefore, 
fatty degeneration of renal epithelium. Not accepted, since the 
changes in the blood are not so great as formerly thought and the 
"hydremia of pregnancy" has been shown to be rare. 



NOTHS ON OBSTErRICS—SIiXIOR CLASS. 263 

Fourth — Spasm of the renal arteries, therefore, fatty degenera- 
tion (Cohnstein). Merely hypothetical. 

Fifth — Increased work of the kidney during pregnancy. Plaus- 
ible. Seems possible that a kidney overworked would suffer, espe- 
cially if it were previously affected, e. g., by chronic Bright's dis- 
ease or infectious diseases. 

Sixth — That the changes are due to an auto-intoxication. Sc me 
noxious products of an "intermediate metabolism" aft'ecting the 
structure of the kidney. 

It is now quite generally believed that the kidneys in pregnancy 
are easily aft'ected by the poisons which they are called upon to 
eliminate. If altered by antecedent disease, the poisons that should 
normally be eliminated may alter its structure. If the liver action is 
insufficient, the products of its own, and the general metabolism, the 
poisons absorbed from the intestine, are not prepared properly for 
excretion by the kidney, which, therefore, suffers in integrity. The 
toxins (for such these under-''metabolized" substances become), ac- 
cumulate in the system, rendering the liver still further inefficient — 
a circulus vitiosus being formed. 

PATHOLOGICAL ANATOMY. 

We must distinguish sharply between inflammatory conditions 
and those which are simply due to pregnancy. Here great dif- 
ficulty arises, especially clinically. 

I. The kidney of pregnancy — (By this term w^e must understand 
those changes in the kidney which occur in a previously healthy 
organ simply as the result of pregnancy). 

The kidney is large, pale, cloudy ; markings obliterated ; contains 
small amount of blood. Microscopically. Fatty changes in the 
glomeruli and tubules, but no signs of inflammation. Changes due 
to ischemia. After labor, the changes disappear. Until now it has 
not been demonstrated that a kidney of pregnancy can be the starting 
point for a chronic inflammation of the kidneys. Cases which tend 
to prove this view are almost always to be explained by a non- 
recognized kidney trouble existing before pregnancy and aggravated 
by pregnancy. If an acute nephritis supervenes, it may be followed 
by the chronic form. 

The changes in the urine in this form of kidney are — specific 
gravity, normal, ma}- be slightly increased. Normal in amount ; little 
albumen, j4 gi^i- to litre, white blood corpuscles, ureter and bladder 
epithelium, a few fatty renal epithelia, hyaline tube casts, and per- 
haps a few granular casts; urea less — 1^4 to iy^%. Later, oliguria 
and numerous casts, but now it begins to be pathological. 



264 NOTES ON OBSTETRICS—SENIOR CLASS. 

II. Various Forms of Bright' s Disease : 

Chronic Interstitial Nephritis — Cirrhosis of the kidney, accom- 
panied by concomitant affections, e. g., Hypertrophy of the heart, 
hard pulse, large amount of watery urine of low specific gravity. 

Chronic Parenchymatous Nephritis — Changes similar to that of 
kidney of pregnancy and hard to differentiate, clinically. 

In general, the effect of these lesions by pregnancy is to intensify 
them. Eclampsia is more likely to occur. 

III. Acute Nephritis — The worst complication of the kidneys. 
Urine scanty, high specific gravity, red in color, cloudy, blood and 
sometimes blood casts. White blood corpuscles, casts of all kinds. 
Convulsions occur in a large per cent. 

Nephritis during pregnancy is more likely to occur if the patient 
have recently had some acute infectious disease, e. g., scarlatina, 
variola, measles. Part played by the kidneys in these diseases now 
known to be much more important than formerly believed. Further, 
exposure to cold and wet increases tendency, or poor living. Still 
fi.nd cases of eclampsia among the well-to-do. 

Symptoms — The kidneys of pregnancy seldom makes symptoms 
of gravity, save a more or less marked edema; the urinary findings 
have been mentioned ; they • are similar to that of chronic paren- 
chymatous nephritis. 

Primiparae are ofteuest affected by this condition, and it begins 
usually in the later months of pregnancy. While symptoms of renal 
insufficiency are mild or absent, the presence of edema and al- 
buminuria should put the physician on his guard, but such symptoms 
may develop suddenly, upon a slight, perhaps unrecognized, cause 
and rapidly bring a fatal outcome, through eclampsia, premature de- 
tachment of the placenta, etc. 

Should the symptoms of a case in which the diagnosis of the 
kidney of pregnancy had been made, aggravate, the case had better 
be considered as one of nephritis and so treated. 

Acute nephritis is an occasional sequel to the kidney of preg- 
nancy, and when it occurs almost always has eclampsia as a symp- 
tom. The cause of this complication may be exposure to cold and 
wet, especially if there has been antecedent septic disease, scarlatina, 
etc. ; various toxic influences, particularly toxemia of pregnancy, 
previously considered. 

These conditions may develop a latent chronic nephritis, especial- 
ly the chronic parenchymatous, making it impose as a new disease 
of the kidneys, "unless its previous existence be known. Rarely can 
it, during pregnancy, be proved to have existed before. 

The symptoms of an acute nephritis and of an acute exacerba- 
tion of a chronic nephritis are : edema and puffiness of the eyelids 
and ankles, or wandering edema, which appears even when the 



NOTES ON OBSTETRICS—SENIOR CLASS. 265 

patient is lying down, in distinction to the edema of venastasis, which 
is better when patient assumes the horizontal position. The ana- 
sarca may be general and is sometimes enormous. 

The labia vulvae are sometimes as large as one's wrist, and 
translucent. Hydroperitoneum and pleura may occur. Pallor, or 
pasty color of the face, especially in chronic forms. Arterial tension 
is increased. The lungs may become edematous and cause death. 
The breath may be urinous. Symptoms of urinemia, or of toxemia, 
the terms being practically synonymous, appear early, and in some 
instances quickly lead to convulsions. Headache, neuralgias, pain 
in epigastrium, disorders of the special senses, spots and flashes in 
the field of vision, partial or total amaurosis (without retinal find- 
ings), dizziness, deafness, tinnitus aurium, delirium, nausea and 
vomiting, but above all, the occurrence of convulsions, eclampsia, 
(See toxemia.) 

Other symptoms are, diarrhea, dyspnea, local palsies (due to 
edema of parts of the brain), general pruritus, numbness and tingling 
of the fingers, cramps in the muscles, especially of the legs. 

The urinary findings have been given. They vary with the in- 
tensity and acuteness of the disease. In acute nephritis there is 
more blood than in the chronic parenchymatous. Books on general 
medicine for further study. 

Chronic interstitial nephritis is characterized by the large amount 
of watery urine w^ith low specific gravity, little albumen, very few^ 
casts, low urea per cent. ; hypertrophy of the heart and increase in 
arterial tension and thickening of the vessel w^all. 

The many symptoms of urinemia or toxemia alread\- mentioned 
may appear, especially as the pregnancy advances, w^hen the dis- 
tinction between the various forms of nephritis becomes blurred. 
Retinitis albuminurica is more common in this form than the others. 

The influeftce of pregnancy on chronic nephritis, therefore, is 
bad. It may light up a latent and aggravate a chronic inflammation 
of the kidney, and it often hastens death, even when eclampsia does 
not occur. Repeated pregnancies are especially bad, the condition 
becoming worse each time, to remain so in the intervals. Labor, also, 
like any severe operation exerts a noxious influence on the kidney. 
Post partum hemorrhage is favored. 

In the puerperium, even, the danger is not past because sepsis, 
although mild, may produce renal insufficiency and nephritis cannot 
bear infection well. 

Anemia is badly borne by women with nephritis. On the other 
hand, the influence of the nephritis (and this includes the kidney of 
pregnancy, too), on the pregnancy is a bad one. Abortion and 
premature labor are common. 

This is brought about — 



266 NOTES ON OBSTETRICS— SENIOR CLASS. 

(a) By the hemorrhages, which are so commonly found in 
the placenta in these cases. These sometimes cause 
numerous white infarcts and sclerosis of the blood ves- 
sels, which cut off the fetal circulation, ''placenta al- 
buminurique" of the French. 

(b) Premature detachment of the placenta, which jeopardizes 
both lives greatly. 

(c) The accumulation of urea, or perhaps better, the toxins, 
in the fetal blood, poison it, and its expulsion follows 
sooner or later. These poisons may irritate the uterus 
and bring on contractions, and finally, 

(d) The occurrence of eclampsia often terminates the gesta- 
tion. 

The Prognosis of all forms of nephritis is bad, both for the 
mother and child. The kidney of pregnancy usually disappears after 
labor, and unless something is added to it, offers a good prognosis, 
though, as was said, the condition needs close watching, especially 
as the diagnosis may be wrong, a more serious lesion underlying 
mild symptoms. It is safest to consider every case where there is 
a moderate amount of albumen" or casts, even though few, as patho- 
logical. 

The main dangers of nephritis are, eclampsia, edema of the 
lungs, hydro-pleura, — pericardium, enormous anasarca, retinitis al- 
buminurica (often leading to permanent blindness). This condi- 
tion, appearing in the course of a chronic nephritis, means that 
the patient cannot survive more than two years. 

For the child the prognosis is bad for the reasons already 
given. 

Treatment — Prevention better than cure. A nephritic should 
not marry', and if married, should not conceive. 4f a woman has 
had eclampsia in her first pregnancy, but has gotten well without 
symptoms of a permanent change in the kidneys, there is no danger 
usually in the next pregnancy, since she may have had simply the 
kidney of pregnancy, which, as was said before, has not been 
proven to result in chronic nephritis. Any symptoms of chronic 
nephritis existing before pregnancy should direct your attention to 
the kidneys, and this emphasizes the need of careful examination of 
the urine. 

A cure can rarely be effected during pregnancy. Best that we can 
do is to tide the patient along till the end of pregnancy, or at least, 
till the fetus is viable ; and then induce premature labor. 

Only real curative treatmeni is abortion. Statement is questioned 
by some. 

Treatment is : 



NOTIiS ON OBSTETRICS—SENIOR CLASS. 267 

I. Hygienic. 
11. Medical. 

III. Obstetrical. 

Hygienic — Diet — Limit nitrogenous foods, make the diet largely 
of milk and starches. No meats or eggs. Alkaline water to drink. 
If necessary, i. e., if no improvement, absolute milk diet. 

Clothing — Should be warm and woolen, even in summer, so as 
to keep up a perspiration, but the patient must beware of catching 
cold. 

Bathing — Systematic use of the hot water pack, or bath. Jac- 
quet's wet packs, or the alcohol packs, or a vapor bath — the fun- 
nel introduced under the bed clothes and an alcohol lamp. 

Danger of abortion from the hot bath may be avoided by giving 
gr. XXV of Chloral before it, or gr. ^ morphine. 

Bozvels — Kept freely open w4th salines. 

II. ]\Iedical Treatment — Very little value in medicines. Treat- 
ment the same as that for the non-pregnant state, e g., alkaline 
diuretics (no potash salts), or Tr. Ferri Chlor. or Infus. Digitalis. 

Cathartics — Jaborandi and Pilocarpine — Dangerous, since if they 
do not produce sweating they depress the heart, or they may cause 
edema of the lungs. If the patient has a convulsion, or is coma- 
tose, the drug sometimes causes such a profuse secretion of saliva 
that this obstructs the air passages. In general, it is not to be 
used. 

III. Obstetric Treatment — A faithful application of the previous 
remedies may often prevent the case from coming thus far, but 
if in spite of daily hot baths, or the Jacquet pack, renewed thrice 
a day, and the hygienic regulations — the dropsy increases, a tendency 
to sleep indicates the approach of coma, cerebral symptoms de- 
velop ; it is time to end pregnancy. 

Experience proves that if the pregnancy come to an end in a 
large majority of cases, the symptoms subside, to a point they had 
before the pregnancy or but slightly worse. 

WHEN TO INDUCE ABORTION. 

''When, in spite of the absolute milk diet, hot packs or baths, the 
edema increases, uremic symptoms (headache, visual disturbances, 
intestinal symptoms, etc.), persist or increase, after at least eight 
days' treatment, may induce abortion." Since these conditions occur 
more frequently in the latter months, the case usually needs pre- 
mature labor. 

Simplest and safest 'method of inducing; labor is the hot water 
bath without drugs. The other methods we will take up under Oper- 
ative Obstetrics. 



268 NOTES ON OBSTETRICS—SENIOR CLASS. 

THE CHANGES IN THE BLOOD. 

Pregnancy alters the blood in healthy women (see ist year 
notes). If a woman is anemic, chlorotic, the condition is likely to be 
exaggerated during pregnancy. These women are usually sterile; 
if they conceive they often abort. They stand labor and especially 
post partum hemorrhage poorly, and they often cannot nurse their 
children, either no milk or poor. 

Pernicious anemia may develop during pregnane}-; it may re- 
sult from a chlorosis, though this is not proven. The theory that 
poisons developed during changes incident to pregnancy, of a hemo- 
lytic nature (as studied by Quincke and Peters), alter the blood, ap- 
peals to me. The vomiting and digestive disturbances of the early 
months may cause anemia, and lay the foundation for graver dis- 
eases. Chronic auto-intoxication from coprostasis is said to be 
causative. 

Premature labor is almost always caused by the affection, prob- 
ably the result of fatty degeneration of the placenta and decidua. 

The patient may die during labor from hemorrhage, which 
need not be large, or the disease may progress so rapidly after 
labor that it is quickly fatal. No case survived two vears (P. Mul- 
ler). 

Perhaps arsenic and bone marrow may save more of the cases. 
Artificial termination of pregnancy has delayed the fatal end in 
but few instances. 

Leukemia sometimes begins during pregnancy, and has like\vise 
a deleterious influence on this function, while the latter aggravates 
the former. Hemorrhage during labor is especially dangerous. The 
child may be leukemic. The treatment of these blood diseases is 
identical with that of the non-pregnant stat€. The interruption of 
gestation is seldom indicated, unless in the interest of the child. 
The white blood corpuscles do not pass over into the fetus. If 
the disease is recognized very early abortion is sometimes justifi- 
able. Hemorrhage during delivery is to be strenuously avoided. 
Lactation must be forbidden. 

Hemophilia is a rare complication of pregnancy ; in women, only 
one in thirteen cases. Menstruation may be free. It does not usual- 
ly disturb the pregnancy, but all hemorrhage is likely to be profuse, 
post partum hemorrhage especially, and sometimes fatal. Bleed- 
ing sometimes occurs from the nipples during nursing, or from 
the genitals. 

The disease may not be known to exist till a pregnancy super- 
venes, or it may develop after several labors, or even in the meno- 
pause, and then lead to fatal end. The cause is unknown. Either 
the blood vessels do not contract or the blood does not clot. The 



NOTES ON OBSTETRICS—SENIOR CLASS. 269 

coagulation time of the blood is undoubtedly increased. Heredity is 
almost always determinable, but there are cases which are acquired. 

Treat 111 cut — During pregnancy give iron, arsenic. Calcium 
chloride (gr. xv t. i. d.), during the week before labor, and gelatine 
freely in the diet. Have everything ready for post partum hemor- 
rhage — gelatine and gauze for packing uterus, etc. 

Morbus maculosis Werthofi, occasionally complicates pregnancy. 
The prognosis is not good, although abortion is seldom. Hemor- 
rhages during gestation may so weaken the woman that a slight 
bleeding during labor may prove fatal. It may occur during the 
puerperium, and may be transmitted to the fetus. The role of the 
adrenal glands in these hemorrhagic diseases needs study. 

THE PELVIC JOINTS. 

The softening and relaxation of the pelvic joints, especially of 
the pubis, referred to in the physiology of pregnancy, may increase 
to such an extent as to become pathologic. Toward the end of 
gestation pains are experienced about the pelvis, especially at the 
joints, and soon extending down the thighs. Locomotion becomes 
progressively more difficult, in the worst cases the patient being- 
bedridden. The pains are worse the longer the patient is erect. 
While there are no paralyses, the patient cannot abduct or adduct 
the thighs without pain. The pubes are tender to touch and one can 
usually feel a groove in the joint and riding of the bones when 
the legs are moved, both on internal and external examination. The 
malady increases until labor, then quickly disappears, but the pa- 
tient may be a little slow in getting up. It is likely to reappear in 
subsequent pregnancies. It may lead to spontaneous or traumatic 
rupture of the pubic joint during delivery. 

The treatment is rest, and a tight pelvic girdle, though little 
relief is obtained till after delivery. 

The second class of diseases during pregnancy — Those wdiich 
are entirely Accidental. 

In general, pregnancy aggravates diseases which occur ; further, 
the pregnancy itself is endangered by them. Acute febrile diseases 
constitute the first and more important class of diseases under this 
head. 

The exanthemata; measles, typhoid (may be reckoned here) ; 
scarlatina, especially variola, have a very deleterious effect on preg- 
nancy, in a large per cent, abortion occurring. It is not true that 
pregnancy confers immunity against these diseases, as was former- 
ly supposed. On the ' contrary, an increased tendency to acquire 
the disease in a prevailing epidemic has in a few cases been recog- 
nized. 



270 NOTES ON OBSTETRICS—SENIOR CLASS. 

There is a tendency for all these diseases to become hemorrhagic 
which clouds the prognosis. There are often profuse menorrhagias 
which are called pseudo-menstruation, or epistaxis uterina. Possible 
that some of these are early abortions. 

The action of these diseases is two-fold : 
. 1st. They may directly interrupt pregnancy by a hemorrhagic 
endometritis. This has influence, first, according to the time of its 
occurrence (bad if early) ; second, its site (worst if in the decidua 
serotina) ; and third, its extent. 

The death of the fetus may be the result of this endometritis. 

2nd. They directly endanger the woman by the complications, 
e. g., hemorrhage, high fever, and puerperal diseases they induce 
or favor, e. g., influenza favors sepsis. A woman exhausted by 
disease is in bad condition to stand abortion or labor. 

The death of the fetus may be brought about in various ways. 
Not all to be mentioned are positive, however. 

1. The fetus may die from insolation. 

The fetus has, of course, the same temperature as the mother, 
and since it has its own heat regulating apparatus can react tq 
stimuli coming from the mother. Normally, the temperature of 
the fetus is a little higher than that of the mother (^ degree F.). 
The fetus has not the means to accommodate an excess of tempera- 
ture, by evaporation, so that a rise of temperature is less well borne. 

The fetus is, therefore, more susceptible than the mother, and 
this is especially true of sudden changes. A rise to 104 is dan- 
gerous for the fetus, and if it continues for any length of time, the 
fetus usually dies, and then abortion follows. If the rise is very 
gradual, the fetus may stand it longer. 

The movements of the fetus are first increased, the fetal heart 
tones also, later both get slower and the fetus dies. Experiments 
on rabbits have shown that a very gradual rise of temperature to 
109 is not necessarily fatal. If sudden, always fatal. On the 
human there are no clinical data other than those given. 

2. Pregnancy may be interrupted by too early uterine contrac- 
tions, elicited by the hot maternal blood circulating in the uterus. 
Theory considered doubtful by some authors. Still, the use of the 
hot douche is advised to hasten labor pains (Winckel). 

3. The fetus may die of asphyxia. This may be brought about 
in various ways : 

(a) The weak heart of the mother may not be able to pro- 

pel the blood to the uterine sinuses, therefore low 
blood pressure, or the low blood pressure, may result 
from severe maternal hemorrhages. 

(b) There may be a large hemorrhage in the decidua sero- 

tina. 



NOTES ON OBSTETRICS—SENIOR CLASS. 271 

(c) The febrile process may have caused such changes in 
the chorionic vilh that the interchange of gases is 
much interfered with. The condition is one of fatty 
degeneration of the viUi. 

How far this is in connection with the endometritis is not cer- 
tain. 

4. The fetus may acquire the disease from which the mother 
is suffering. The placental wall offers no hindrance to the pass- 
age of toxines from diseases, but the passage of bacteria requires 
some lesions of the wall, which is not hard to find. Numerous 
micro-organisms have been known to pass through. 

The typhoid bacillus, the pneumococcus, spirillum of relapsing 
fever, streptococcus, staphylococcus, bacteri coli communis have been 
demonstrated in the fetus. 

The fetus has had a chill in utero and been born with an enlarged 
spleen, "ague cake." Likewise, smallpox can affect the child, it- 
being born pock-marked. Vaccinia, also, the new born not being 
susceptible to vaccination. It has not been proven that scarlet 
fever, cholera, erysipelas, rabies, tetanus, can pass over to the fetus, 
though for some it seems highly probable. 

The effect of these diseases on the mother is variable. Pneu- 
monia is bad, because of the difficulty in respiration, the strain of 
labor may prove too much for the already overburdened heart and 
lungs. If labor comes on (which should be prevented if possible), it 
should be terminated as quickly as possible. The respiratory dif- 
ficulties may be so great that it is necessary to terminate pregnancy, 
though this is itself a risky procedure and may defeat its own pur- 
pose. 

Influenza may act like a pneumonia and requires the same treat- 
ment. Some epidemics are m.ore fatal than others, e. g., Hintze re- 
ported eight cases with three deaths, and pus with pus germs were 
found in the uterus. The cases may be mild and the child may be 
affected, too. Occurring in the puerperium it may simulate puer- 
peral fever (if it may not directly favor it). Treatment, on general 
principles. 

SEPSIS. 

May occur during pregnancy. Cases are not rare where women 
are infected in the last month ; the labor is soon evoked, and the 
child is almost always dead. The writer believes that infection, at 
this time, from coitus, the examining finger, douches, etc., is more 
common than is generally believed, and that this fact sheds an im- 
portant light on many, of the complications of labor and the puer- 
perium. 

Albert holds this view and says that the Infection may be older, 



272 NOTES ON OBSTETRICS—SENIOR CLASS. 

may date from a previous labor, or an endometritis that has been 
present for years, 

GONORRHEA. 

The importance of this infection is getting wider attention each 
year. That it can cause steriHty in both sexes is certain ; that it can 
cause abortion, and premature detachment of the placenta, has been 
asserted. It may cause sepsis post partum. (See path, of the puer- 
perium.) 

The so-called ''puerperal rheumatism" may be a gonorrheal in- 
fection of the joint. Acute gonorrhea during pregnancy, profuse 
discharge, greenish, condylomata acuminata, Bartholinitis, sal- 
pingitis, peritonitis, dysuria, etc. 

Treatment urgent, because of complications of puerperium and 
ophthalmia neonatorum; 1/1500 permanganate of potash douches, 
painting vagina with 20% argyrol sol., light tampon of iodoform 
gauze, etc. 

TUBERCULOSIS. 

This has a marked influence on the genital function of the 
female. 

First. Menstruation, in advanced cases, is usually suppressed. 
This is due to the weakness of the constitution, the conservative 
efforts of nature, or to atrophy of the ovaries, or to some local tuber- 
cular trouble in the genitalia. 

In the beginning of a tuberculosis the menses often become ir- 
regular and scanty, as occurs often in chlorosis, and the hard diag- 
nostic problem may arise. Beginning tuberculosis or chlorosis ? The 
tuberculosis perhaps is the cause of the other. Leucorrhea is often 
a symptom in tuberculosis and there need be no local affection, this 
taking place instead of the menses. 

STERILITY. 

Fortunately, is not rare in tuberculous subjects. Due to the 
same causes as the amenorrhea, but the influences are only observed 
in advanced cases. 

During pregnancy only rarely does abortion occur, a little oftener. 
premature labor. Still, in a large per cent, of cases the pregnancy 
goes to term, and the patient may die during the labor, but usually 
unless in the cases near death anyway, there is no trouble. Post 
partum hemorrhage, hemorrhage of the lungs, edema of the lungs, 
have been noted as complications. Pregnancy does not confer any 
immunity on women against tuberculosis, as was formerly thought. 
Indeed, the tendency to become tubercular, if there is any taint in the 
family, will be developed now. 



NOTES OX OBSTETRICS—SENIOR CLASS. 2*73 

An existing tuberculosis is sometimes apparently benefited, but 
after labor the disease makes more rapid progress, the caseous de- 
posits soften and break down. The reason the tubercular tendency 
remains latent till puberty or gestation, is not known ; also, it is not 
understood why these should have such deleterious influences. 

The disease sometimes makes rapid progress during pregnancy. 
During the puerperium, involution proceeds normally. Lactation is 
likely to be insufficient, and if the woman nurses the progress of the 
consolidation is very rapid. Hectic often develops. 

In Regard to the Fetus — The undoubted transmission of a ten- 
dency to the tuberculosis is hard to explain. 

That the tubercle bacilli can pass through the placental wall is now^ 
quite certain, for animals as w^ell as man, but cases of congenital 
tuberculosis are very rare. They are always from the maternal 
side, though it is certain that in advanced tuberculosis bacilli are 
expelled with the semen. 

The fetus is apt to be poorly developed, but exceptions to this 
are not uncommon, large and fat children have been born of ema- 
ciated mothers. 

Clinical fact that children of tubercular parents are not so hardy 
as others ; they die of tubercular meningitis, intestinal diseases. A 
certain number die of tuberculosis, which they acquire from the 
mother's milk. This point is not definitely proven, but there is a 
high degree of probability. 

Women with tuberculosis should not marry — first, because this 
aggravates their own disease ; second, they may infect the husband ; 
and third, they propagate tuberculous children. Same is to be said 
of the husband. 

If the tuberculosis is latent, or if they possess only the hereditary 
taint, the question is more difficult, but it is only exceptionally that 
the doctor's advice is asked. Knowing the tendency for a latent 
tuberculosis to break out in pregnancy, marriage is to be forbidden. 
If the woman marries she should avoid conception. Finally, if she 
conceives she should not nurse the baby. The disease makes great 
progress during the puerperium, especially if the woman nurses. 

During pregnancy, expectant treatment unless some severe symp- 
tom arises, e. g., very rapid consolidation, pulmonary hemorrhage, to 
which the tendency in the latter months is increased. x-Vbortion is 
rarely indicated. May be necessary to induce premature labor, 
though rarely, and denied by some authors. The w- eight should be 
taken weekly, and if there is a steady gain danger is seldom pres- 
ent. During labor the patient should not be allowed to suffer longer 
than necessary. Caesarean section, post mortem, has been frequent- 
ly done in cases which die in pregnancy or labor. 



274 NOTES ON OBSTETRICS—SENIOR CLASS. 

SYPHILIS. 

This disease is of the greatest importance to the Obstetrician. 
The disease is quite common. Ricord says that in Paris one in eight 
is syphiHtic. In the U. S. the conditions are much bettter, but still 
one must expect the cases frequently. There is no doubt that 
there are a good many cases which are not diagnosed. We have to 
consider syphilis as it manifests itself from the mother, and secondly 
from the father. The former is more important, as it afifects the 
fetus more deeply; the latter is important in that it may show itself 
after all the manifestations of the disease on his part may have 
disappeared. Limit of safety has not been determined, given from 
4 to 12 years after appearance of disease. (See Rosinski on Syph- 
ilis.) 

In general, syphilis is graver in the pregnant state than in the 
non-pregnant. Primary and secondary lesions are usually observed, 
as, owing to the age of the patients, tertiaries have not developed. 
The chancre is more voluminous than ordinary, hypertrophied, vas- 
cularized, and softer, because of the general softening of the parts, 
whether pathological or norrnal. 

The glands are enlarged more than usual, and are painful. There 
is, also, more of a tendency to suppuration. The length of per- 
sistence of the primary lesion is greater, lo to 12 weeks being the 
average. 

The eruptions on the mucus membranes and skin are also more 
marked. The eroded papules are very numerous on the vulva (Four- 
nier). ''They develop with a singular exuberance, take on quickly 
a granulating condition, hypertrophy, and often constitute veritable 
tumors, which invade and deform the entire vulva. Further, they 
are always more rebellious to treatment, being reabsorbed slowly 
and with difficulty. The ulcerating syphilides are very frequent in 
pregnant women, livid, purple, excavated, which is increased by the 
general tumidity of the parts. They persist longer and have a 
tendency to become phagedenic." 

General Symptoms — In pregnancy, the general symptoms are ag- 
gravated by syphilis. The anemia is more profound, troubles of di- 
gestion more marked, neuralgias, headaches, insomnia, much more 
common. Neuralgias beginning shortly after marriage often point 
to syphilis. Eclampsia and urinary troubles are not more frequent. 

Labor may be influenced by syphilis. It is said that the pains 
are more painful, due to exaltation of the nervous system. 

A chancre on the cervix may impede the delivery, and there is 
a secondary manifestation of syphilis in the cervix, a thickening in- 
duration of the tissues, which render dilatation much more dififi- 



NOTES ON OBSTETRICS—SENIOR CLASS. 2 75 

cult, sometimes impossible, necessitating incisions, craniotomy, etc. 
Has been fatal. 

Friability of the perineum is sometimes observed, especially if 
there are condylomata. The perineum may tear like wet paper. The 
puerperium shows a rapid healing (with treatment) of the florid 
lesions. There is a slightly greater tendency to infection from the 
lacerations, the general ill-health, etc. ; there is no real syphilitic 
fever, which has been asserted. 

Post partum hemorrhage is not more frequent. The placental site 
is often thrombotic from death of the fetus. That syphilis can pro- 
duce a blood dyscrasia similar to hemophilia has occurred to the 
author as probable. 

Maternal — Syphilitic women are often sterile, — reason not 
known ; may be ova are no good. 

The effect of maternal syphilis on the pregnancy is marked, but 
varies with the age of the syphilis and the treatment instituted. 

1. Syphilis contracted before pregnancy. 

In these cases usually a series of abortions occurs, each one later 
than the last ; later, premature labors, the fetuses either born macer- 
ated or dying a few hours or days after birth. Finally, living chil- 
dren at term, which show sooner or later the signs of hereditary 
syphilis, or with treatment grow up. This course of events can be 
broken if the proper treatment be instituted. 

Rarely healthy children are born of a syphrlitic mother without 
treatment. These cases are of old, mild syphilis. It is not known 
how long it takes virus of syphilis to become attenuated, so that liv- 
ing, healthy children may be born. The longer the syphilis, the 
more the likelihood. Somer reports a case of syphilis in a child lo 
years after the infection. 

Ruge says 83% of repeated miscarriages are due to syphilis. 

2. The woman acquires the syphilis at the same time she becomes 
pregnant : 

Abortion is the rule, unless vigorous treatment is given, from 
the start. Even here the child is usually lost, which must not weaken 
our efforts to save it. 

Subsequently, the cases are the same as No. i. 

3. The syphilis is contracted during pregnancy. If early it 
usually leads to abortion. If in the last two or three months, the 
fetus escapes in about one-half of the cases and is born healthy at 
term. In very rare cases the fetus may become inoculated during its 
passage through the genital tract, but then the case is one of acquired 
syphilis. 

If the child is born alive, it is immune to primary syphilis, the 
poison having been absorbed while in the uterus. Thus it may nurse 
a syphilitic mother and not be re-infected. 



276 NOTES ON OBSTETRICS—SENIOR CLASS. 

In the same way a syphilitic child may infect its mother. The 
mother may thus develop secondaries without any primary chancre 
being formed. 

The syphilitic spermatozoid has infected the ovum, the mother es- 
caping while the child is developing. 

Paternal Syphilis — Influence not so important, still is marked, 
and is harder to understand. 

1. When the husband has florid primary or secondary lesions 
and infects the wife at the same time as he impregnates her. Here 
it is impossible to separate the results of the paternal and maternal 
syphilis. Abortion is the rule. 

2. The more common case is : the husband has had syphilis and 
has been treated more or less thoroughly several years before his 
marriage. At the time of the impregnation he has no infective 
lesions. The child is usually, but not always, syphilitic, or it may 
show signs of syphilis later in life, at the time of puberty. The 
mother may escape entirely, or be infected from the child through 
the uteroplacental circulation. 

If the syphilis be more recent in the man, the w^oman may abort 
or have premature labor, with a macerated fetus. If you treat both 
man and woman, the subsequent children are born ali^e. 

An interesting condition arises here. The woman has a syphilitic 
child within her. Does she become syphilitic? No, and yes. No, 
because she has no signs of the disease; yes, because she cannot 
be infected with syphilis, and responds to treatment, as is shown 
by healthy children later. 

In rare cases the patient may show signs of secondary syphilis 
without any trace of a chancre. These are cases of syphilis by con- 
ception. 

SIGNS OF SYPHILIS ON THE FETUS. 

1. The characteristic change in the epiphyses described by Weg- 
ner. The line of ossification is broader, with irregular edges and 
points running into the cartilage. There are small islands of bony 
matter off to the side in the cartilage and the whole epiphysis is 
yellower. In advanced cases the part is swollen, the periosteum 
thickened. The condition is said also to occur in congenital rachitis. 
This is denied by the majority of authors, and again, rickets is ex- 
cessively rare. The diaphysis breaks off easily. In mild cases the 
change may be moderate, and sometimes even in normal cases 
the line of ossification may be a little wavy. Therefore, it may 
be hard to distinguish. 

2. The liver and spleen are larger. Ordinarily the propor- 
tion of the weight of the liver to that of the body is one to thirty. 



NOTES ON OBSTETRICS—SENIOR CLASS. 277 

The spleen i to 300. In syphilis the weight is increased three, and 
even four times. 

3. The lungs may present gummata, or a peculiar interstitial in- 
filtration, which is characteristic of syphilis or a catarrhal inflam- 
mation, called white pneumonia, incompatible with respiration. 

4. Changes in the skin. Bullous eruptions — exfoliation of large 
areas, condylomata, etc. 

5. The placenta is larger, heavier, fatty — presenting the macro- 
scopical and microscopical changes, to be considered under the 
pathology of the placenta. 

6. If the child lives, it may be affected with pemphigus and other 
skin lesions, the hemorrhagic diathesis, icterus gravis, and then the 
usual evidence of congenital syphilis. 

Treatment — Now, no doubt about the propriety of treatment dur- 
ing pregnancy. Instituted early, it may prevent abortion; and al- 
ways tends to cure the disease. So that here, as usual, the indica- 
tion is to treat syphilis vigorously. Methods the same as ordinarily 
given. 

In cases of repeated miscarriages with definable cause, it is a 
good plan to give the mother mercury throughout the pregnancy — 
gr. 1/50 HgCU three to four times a day. 

Nursing — Shall a syphilitic woman nurse her child? Where the 
patient has presented signs of syphilis, she may nurse her child, 
even if the child show no signs of syphilis. No case is on record 
(Fournier) where a syphilitic mother infested her own child. Where 
the father is syphilitic, the mother free, the proper one to nurse the 
child is the mother. (Law of CoUes.) In certam cases a wet nurse 
has been employed and there has been no infection, but do not as- 
sume the responsibility. Recommend the careful supervision of the 
lips of the baby for "patches" in all cases. 

Do not put a syphilitic child to a healthy wet nurse. Parvin 
says it is criminal. 

HEART DISEASE IN PREGNANCY. 

Pregnancy is accompanied by enlargement of the heart, a hyper- 
trophy, for which there are many reasons ; general increase of all 
of the body functions, increased intra-abdominal tension, increase of 
the total amount of the blood, and in the area of the circulation (pla- 
cental circulation), uterus and pelvic organs larger, and the in- 
crease of the weight of the body. 

Larcher, in 1826, showed the increase of the weight of the heart 
to be one-fourth to one-third, in autopsies on 130 cases of puerperal 
women. Blot, in 1862, came to the same conclusions. 

The Germans, following Gerhardt, believe there is little, if anv. 



278 NOTES ON OBSTETRICS—SENIOR CLASS. 

h}-pertrophy ; that the enlargement is only apparent, due to the lifting 
of the heart by the diaphragm and its being pushed forward, the 
chest becoming shallower. 

That there is at least a slight hypertrophy of the left ventricle, 
most authors beUeve. 

The diseases of the heart may be divided into those which were 
present before, and those which develop during, pregnancy and 
the puerperium. Pregnancy may occur with all forms of cardiac 
disease. If the heart is doing its work well it may meet the addi- 
tional demands satisfactorily ; if the disease is advanced, if the heart 
is in a condition of unstable equilibrium, especially if there is myo- 
carditis, the danger of lack of compensation is present, and of a 
degree in accordance with the conditions. 

Pregnancy is often, one-fourth of the cases, interrupted, and 
usually in the latter half, due to pelvic congestion; hemorrhage, 
venosity of blood, coughing, death of the fetus. 

Pregnancy not seldom disposes to an acute exacerbation of a 
chronic endocarditis, and with this sometimes a fatty degeneration 
of the papillary muscles, with, of course, bad effect on the com- 
pensation. 

Kidney disturbances are invited, and to all this may be added 
the respiratory difficulty, due to overloading of the pulmonary cir- 
culation. The high position of the diaphragm does not decrease 
the trouble, and as a result of all these causes, transudations in the 
pleurae are not rare. Compression of the lungs, hypostatic pneu- 
monia, hemorrhage, edema pulmonum, are sequellae. Dyspnea, 
sometimes very marked, palpitation, cough, edema, ascites, and the 
usual symptoms outside of pregnancy, show the lack of compensa- 
tion, and this may lead to the development of serious conditions 
which may demand obstetric interference during gestation. Myo- 
carditis cases are especially apt to prove unequal to the test of preg- 
nancy, and sometimes, too, fatty hearts. 

During Labor — There is danger from not fully compensated 
hearts. Uterine action increases the arterial tension, and straining 
— bearing down — increases both arterial and venous pressure. Then, 
too, the fluctuations of the pressure are hard on the heart. Symp- 
toms of a laboring organ appear, or the heart may suddenly prove 
default, and collapse, edema pulmonum, and death ensue. If the 
heart holds out till after the baby is born, the circulation may be 
established rapidly, or, in not a few cases, sudden death in collapse 
may occur. 

In the Piierperium, some of the patients that recover from the 
strain of labor grow worse, and die from embolism of the brain, 
etc., recurring endocarditis, degeneration of the heart muscle, and ag- 
gravation of the existing disease, etc. 



NOTES ON OBSTETRICS—SENIOR CLASS. 279 

Fatty heart may cause disturbances of compensation, but usually 
not, unless there be some adjuvant cause, e. g., chloroform, long and 
hard pains, operations, hemorrhage. During the puerperium it may 
be the cause of sudden death. Cardiac thrombosis and pulmonary 
embolism are sometimes the result of heart disease in the puerperal 
state. 

PROGNOSIS OF CHRONIC HEART DISEASE IN PREG- 
NANCY. 

The majority of women with heart disease pass through preg- 
nancy and the puerperal state without trouble. If there is good 
compensation, accidents rarely occur. The worst kind of affection is 
the myocarditis, and especially if this complicates a valvular defect. 
Of the valvular lesions, mitral stenosis is the worst ; then mitral re- 
gurgitation, and, least dangerous, aortic insufficiency. 

All depends upon the compensation, which again depends upon 
the length of time since the deforming disease, the youth and con- 
stitution of the woman, the condition of the heart muscle, and of the 
blood vessels. The integrity of the other viscera must also be 
taken into account. In general, the usual findings and rules are use- 
ful in determining the prognosis in a given case. Von Leyden had 
40% mortality in the severe cases. Jaworski 30%, but I think these 
percentages are too high. 

Treatment — Marriage not to be forbidden unless the disease is 
marked, or compensation is insufficient and unstable. During preg- 
nancy care against strain, catching cold, toxemia, nervous shocks, 
etc. General medical treatment when necessary. 

Obstetrically, expectancy. If the symptoms of bad compensation 
appear, the question of interruption of gestation arises. When the 
heart is proving unequal to the task of the advancing pregnancy, 
labor should be induced ; also, when the disease is making such rapid 
progress that there is reason to fear death will occur during or 
shortly after labor. Pulse valuable index. 

The child is almost always viable, so that its interests do not in- 
terfere. The method of election is the rupture of the bag of waters. 

During labor, expectancy; almost always there is no trouble, but 
be ready to interfere at the slightest indication of it. Puncture the 
bag of waters early, and empty the uterus as rapidly as consistent 
with the safety of the mother. There is no contra-indication to 
chloroform in heart disease cases in labor, unless it be a marked 
myocarditis. 

Watch the woman carefully after the baby is born. Keep hand 
on uterus, and make pressure on the abdomen. Put on a tight 
binder. Digitalis may be given during labor. 



280 NOTES ON OBSTETRICS—SENIOR CLASS. 

In treating labors in cardiac cases, have everything ready for 
instantaneous termination of labor on a moment's notice. Have 
stimulants at hand, including oxygen, and supply of assistants. 

The second class of cases are those that develop during pregnancy 
and the puerperium. It was once thought that a sub-acute endo- 
carditis was peculiar to pregnancy, but not considered any more. 
Acute endocarditis may occur during pregnancy. Acute myocardi- 
tis, and fatty degeneration, may occur during gestation, but they 
are more likelv in the puerperium, as evidences of a septic process, 
though they may occur alone. Brown atrophy has been found in 
many cases of sepsis. Fatty degeneration may follow hemorrhages, 
especially if repeated, and there is observed an acute fatty degenera- 
tion similar to Buhl's disease, of the new born. 

Cardiac palpitation, without organic disease, but due to nervous- 
ness, may be an annoying symptom during pregnancy, even neces- 
sitating its interruption. Basedow's disease has some dependence 
on gestation. There is not much positive interaction between the 
two conditions. 

DISPLACEMENTS OF THE UTERUS. 

The uterus is normally anteverted, and during pregnancy (first 
months) this anteversion is increased. It is very rare that the fundus 
is caught under the pubis, because the angle which the pubis makes 
with the plane of the inlet is a little obtuse — 105 degrees. Bad 
symptoms are almost never observed. 

Late in Pregnancy, the uterus becomes anteverted, owing to the 
weakening and relaxation of the abdominal muscles. The condition 
is called pendulous abdomen, venter propendens, ventre en besace, 
Haengebauch. In pronounced cases, the fundus is between the pa- 
tient's knees. More common in multiparae and it increases with 
the number and frequency of the pregnancies. Occasionally, it ap- 
pears suddenly about the eighth month, due to a rapid giving way 
of the linea alba, and diastasis of the recti. 

In primiparae pendulous abdomen is rare, and must always give 
rise to the suspicion of contracted pelvis. 

Causes, are, increased pelvic inclination, weakness of the ab- 
dominal walls, lordosis, contracted pelvis, kyphosis, spondylolisthesis, 
tumors with pregnancy, twins, hydramnion, enteroptosis. 

During pregnancy it causes a sense of weight and distension, — 
dragging pains in the abdomen, in the back and on the insertion 
of the recti at the chest; intertrigo of lower abdomen and thighs, 
varices and edema. 

Sometimes trouble in urinating, and the protrusion may be so 
large as to interfere with walking, and household duties. It is 
spoken of as a ''rupture," but is only a wide diastasis of the recti. 



NOTES ON OBSTETRICS—SENIOR CLASS.. 281 

During labor the position of the uterus throws the cervix back 
into the hollow of the sacrum, often high up towards the promontory, 
and prevents its proper dilatation. The head may not engage, for 
the same reason, and labor does not progress in spite of strong pains. 
The mechanism of labor is disturbed. ^lalpositions are more com- 
mon, especially breech positions and anterior parietal bone presenta- 
tions, prolapse of the cord or extremities. Diagnosis of the position 
of the child is difficult. Ruptura uteri favored. 

Treatment — Prevention is important. Care of labor and after. 

1. Proper length of time of lying-in. 

2. Application of binder. Said that English women owe their 
good forms to the binder. ]More probably due to their rugged con- 
stitutions and exercise. The binder does more good after getting 

3. Prevention of gas and fecal matter accumulating in intestines. 
Gas distends abdominal muscles and prevents their return to the 
normal state. "High stomach,"' due to fat, gas, etc., pressed down 
by corsets. Therefore, keep bowels open before and after labor. 

4. Infection, causes it by laming the intestinal walls. Some 
gynecologists recommend operation, laying bare and uniting the 
edges of the recti muscles. Not advisable, except in very aggravated 
cases. 

During Pregnancy — Support the uterine tumor with a binder 
which shall lift it up towards the shoulders. Xo corsets. Keep the 
bowels open. Have patient lie on back. This treatment is as much 
to insure a good presentation as to give patient comfort. The 
French use a "ceinture entocique," a binder with pads on either 
side, to keep the child in a longitudinal position and prevent pendu- 
lous belly. 

During Labor — Pull the uterus upward with a towel over 
shoulder and hold in place with another around belly. ^Nlay not be 
able to feel the head per vaginum till you push the tumor up with 
the outside hand. The Walcher position may be tried for an hour to 
facilitate the engagement of the head. King advises to put the pa- 
tient in a squatting position. The thighs force the uterus up against 
the abdomen. 

Owing to great delay in labor or to danger to the fetus, it may 
become necessary to apply forceps in head cases. The shoulders 
may give trouble, the anterior shoulder being caught on the pubis. 
In breech cases, if there is delay in labor, good plan to go in and bring 
down the anterior foot. This straightens out the fetus and brings 
the uterus into the axis of the pelvis, so that it can work to better 
advantage. 

In some cases the diastasis of the recti muscles is so great as to 
allow the uterus to fall out between them, making a hernia uteri 



282 NOTES ON OBSTETRICS—SENIOR CLASS. 

gravidi abdominalis. The bearing down efforts of the parturient now 
can be of no effect on the deHvery — rather may delay it. 

Ante-fixed Uteri — Owing to the general modern operative treat- 
ment of displacements of the uterus by sewing it to some part in 
front, e. g., abdominal wall, bladder, vagina, cases are accumulating 
of trouble in labor due to the abnormal position of the uterus and the 
interference with the normal processes of labor. Several distinct, 
somewhat typical forms of dystocia have resulted from these opera- 
tions and frequently enough to be considered in a separate chapter. 

The cases may be divided into : 

1. Alexander operation. 

2. Ventro-fixations. 

3. Vesico-fixations. 

4. Vagino-fixations. 

1. Alexander Operation — Restores the parts to nearest the nor- 
mal. Few disturbances have been reported, and these abortions. 
The shortened round ligaments grow and undergo involution as they 
usually do. 

Sometimes there is pain during the later months of pregnancy. 
Uterus is free to grow, but in rising it pulls on its ligaments. 

Treatment — Knee chest position frequently for the pain, and robo- 
rant liniments. Watch for threatened miscarriage. 

2. V entro-Hxations — Here the uterus is sewed to the anterior ab- 
dominal wall. May be in the middle of the corpus, at each side, or 
the round ligaments may be sewed to it. Of these the last given gives 
rise to the least trouble. If the peritoneum has been dissected off so 
that the adhesion is in the connective tissue, the point of fixation does 
not stretch and give way and a relapse does not occur. If the adhe- 
sion does not give or if it is placed too near the fundus, the free part 
of the uterus dilates, the part adherent does not, and there results a 
deformity of the uterus, especially the anterior wall. The uterus 
grows in the breadth, cannot rise high toward the sternum, the poste- 
rior wall is thin, the anterior thick, the axis of the uterus cannot be 
gotten to correspond with the axis of the inlet, the cervix is high, 
over the sacrum and the mechanism of labor is disturbed. 

In 68 cases of labor collected by Lindfors, the cervix was high in 
27, transverse presentation in 31, and trouble in third stage in 10. 
There were 30 versions, 13 Caesarean Sections, 10 high forceps, 5 
embrv'Otomies, 5 tamponades for post partum hemorrhage and many 
other operations necessary. There were three deaths. It is claimed 
by Lindfors if the operation is properly performed, there is almost no 
danger of trouble with succeeding pregnancies. 

In 146 cases collected by Lapthorn Smith there was trouble 36 
times, 10 abortions, 3 deaths. Treatment will be discussed with that 
of vaginal fixations. 



NOTES ON OBSTETRICS—SENIOR CLASS. 283 

3. Labor after vesical fixation has not been observed. 

It would be thought that the gravid uterus in its various move- 
ments would draw the bladder into sympathy with it. 

4. \'aginal fixation as formerly done gave rise to such severe 
disturbances in gestation and labor that its performance on young 
women was discountenanced. Whether the newer method (passing 
the sutures through the round ligaments) will be free from labor 
complications, time will show. The anterior part of the uterus being 
united to the vagina, marked anteversion result with the cervix 
directed upward towards the promontory. The fundus is fixed on 
a relatively immovable body (the vagina). The anterior wall of the 
uterus cannot take part in the dilatation of the uterus, therefore the 
rest of the uterus has to stretch more. The uterus takes on a peculiar 
triangular shape with the broad base over the inlet. 

During pregnancy, pain in the scar, because the uterus grows 
away from the scar. Irritation of the bladder; may have to use 
catheter. Abortion in 25% of the cases, because the uterus is hin- 
dered in its dilatation. In some cases the uterus pulls away from its 
attachments, and then the course of the case is uneventful. 

It seems also that the operation hinders conception. As preg- 
nancy advances the posterior wall of the uterus develops more and 
more, gets thinner, the anterior wall of the uterus remains where it 
is and roofs over the pelvis. 

The cervix is drawn upward and backward toward and somewhat 
above the promontory of the sacrum and in this condition we find the 
parts when labor begins. 

During Labor — 

1. Premature rupture of the bag of waters. 

2. Prolapse of the cord. 

3. Abnormal presentation, most frequent, shoulder presentations. 

4. Post partum hemorrhage. 

History of a typical case is : Labor pains slow, bag of waters 
ruptures early, usually transverse presentation. Ovoid transverse, 
low down, round ligaments run near pubis. Thinning of posterior 
wall of the uterus. 

•Vaginally, roof of vagina smooth, anterior portion drawn up, 
posteriorly the cervix cannot be felt unless the whole hand is intro- 
duced. Anterior lip of the cervix a hard resistant half ring. Poste- 
rior vaginal vault and posterior lip of cervix continuous, forming 
one canal. Cervix at or above promontory. Not all cases are as bad 
as this, but in the bad ones labor seldom terminates spontaneously. 
Almost always an operation needed, unless patient dies of sepsis be- 
fore. 

Treatment — If case is mild, can reach cervix, dilate with col- 



284 NOTES ON OBSTETRICS—SENIOR CLASS. 

peurynter, then version and extraction, rarely forceps. May have 
to make incisions in cervix. Careful in intra-uterine manipulations 
of the thin posterior wall of the uterus. If roofed vagina impassable, 
or cervix out of reach or impossible to do a version (the child lying- 
in a pouch anteriorly). 

There are three methods : 

1. Incisions of the anterior cervico-uterine wall. 

2. Vaginal Caesarean section. 

3. x\bdominal Caesarean section or the Porro operation. If the 

child is dead embryotomy if possible, otherwise as above. 

Posterior Displacements — Retroversion — Rare in nulliparae, but 
when it occurs, the woman is usually sterile. The same may be said 
of retroflexion in virgins. In women who have borne children both 
these displacements are common, but they are very seldom a cause 
of acquired sterility. 

Retroversion of the pregnant uterus seldom remains such, the 
growing uterus gradually lifts itself up and about the third month, 
having passed the promontory, the fundus falls forward. The patient 
knows nothing of it — called spontaneous restitution. If the texture 
of the uterine wall is very- soft the uterus cannot lift itself up, the 
fundus remains in the hollow of the sacrum, the cervix stems behind 
the pubis, the fundus fills up the pelvis and incarceration results. 

Retroversion of the first degree seldom causes any trouble, the 
uterus rising in the abdomen. When of the second degree, if not 
abortion, incarceration usually occurs, though here, too, spontaneous 
restitution is observed. The incarceration occurs earlier than with 
retroflexion because the uterus is longer. The difference berween 
these two conditions lies in the direction of the cervix, which in the 
flexion looks downward, in version directly against the pubis. Par- 
tial restitution may occur. 

In retroversion of the greatest degree, when the cervix looks 
almost upwards, the same conditions may arise, but incarceration may 
occur late — fifth, even to the eighth, month, which is due to the fact 
that uterus really stands on the fundus, this developing toward the 
pelvic floor, the cervix looking upward ("sursum spectat," Hunter). 

When' neglected these cases are very bad (of twenty-two women 
seven died, only six carried through). Hard to empty the uterus 
under the conditions, because the fundus can hardly get by the prom- 
ontory, while the cervix catches on the pubis. 

Causes of Retroiiexio Uteri Gravidi — 

1. Retroflexion before pregnancy. 

2. Seldom that a sudden increase of the intra-abdominal pressure 
can push the pregnant uterus back. ]May be possible when the blad- 
der is full, e. g., coughing, lifting heavy weights, jumping, etc. 



NOTES ON OBSTETRICS— SENIOR CLASS. 285 

3. Pelvic adhesions. 

4. Shrinking of the uterine serosa and muscle at the angle of the 
flexion. 

5. Flat pelvis with prominent sacrum, or tumors which act like 
this. 

Symptoms — Same as those of any tumor in the pelvis. 

1. Disturhance of the bladder — irritation, incontinence, retention. 

2. Constipation, sometimes diarrhea. 

3. Bearing down, sensation of fullness and w^eight. 

4. Pains, radiating from sacral and lumbar plexuses. 

These symptoms occur before the room in the pelvis has become 
entirely too small and usually bring the patient to the doctor. Rarely 
the woman waits till the uterus is tightly wedged into the pelvis. 

Termi nations — 

1. Spontaneous rectification. 

2. Abortion. 

3. partial spontaneous rectification. 

4. Incarceration under promontory. 

I. In the large majority of cases about the third or fourth month 
the uterus rises spontaneously past the promontory and gently falls 
forward. 

The fibres in the anterior uterine wall, the round ligaments, have 
mostly to do with this ; secondarily, the utero-sacral ligaments. This 
may take 24 hours and occur between two examinations by the physi- 
cian. The patient may not notice it. Again, it takes several days, 
which usually means that there are pelvic adhesions. These are 
ruptured, stretched or may be even absorbed. Even extensive 
adhesions may be gotten rid of in this way. The course of the preg- 
nancy is now normal. 

How long to wait before interfering? Better too soon than too 
late. Wait until the third month, and if no signs of ascent — inter- 
fere. 

II. Abortion, has been so frequently observed when the uterus 
was retroflexed that this condition is believed to be a frequent cause 
of the accident. Important cause of habitual abortion before the 
third month. 

Interruption of pregnancy due not to lack of room, but to — 

1. Disturbance of circulation, the result of the bend, causes 

uterine contractions. 

2. Chronic endometritis, result of the congestion, causes the 

death of the fetus by hemorrhage. 

3. Chronic metritis — walls harder and irritable. 

Abortion occurs at a time when the attachments of the ovum are 
slight, and weak. Even if the cervix is much displaced the abortion 
is usually complete. After the abortion or during its progress the 



•^86 NOTES ON OBSTETRICS—SENIOR CLASS. 

uterus returns to its normal position, so that the lochia have free 
outlet. If not, the drainage of the uterus may be incomplete, because 
the fundus is lower than the neck. 

III. Incomplete Restitution, or Retroflexio Uteri Gravidi Par- 
tialis. Here the anterior part of the uterus goes up into the abdo- 
men. Part of the body of the uterus remains in the pelvis and the 
head may be found in this part. Due to relaxed uterine walls and 
adhesions too firm. Also to anomalous form of the organ, to con- 
traction of the peritoneum in the angle of the flexion, tumors. Per 
vaginum find the uterus behind, — cervix high up in front ; may be 
out of reach — above pubis. 

This condition terminates — 

1. Normally at term. 

2. Abortion may occur. 

3. The uterus lifts up the remaining portion. 

4. Incarceration may occur at about the fifth month. 

5. Operation may be needed at time of labor. 

Diagnosis — Is usually simple, but sometimes there is difficulty if 
the positions are not recognized. Bimanual — using the whole hand 
if necessary, under chloroform or ether. Cervix against pubis or 
above it. Soft, fluctuating tumor in the cul-de-sac, containing a part 
of the fetus ; soft tumor above the pubis, both in close relation with 
the cervix. 

A condition known as Sacciform Dilatation of the Uterus is quite 
rare. Resembles ''partial restitution" but is said to have nothing 
common in the cause. Vaginally, same conditions found. DePaul 
had a case, could not find the external os, therefore, punctured tlie 
posterior wall of the uterus. Woman died undelivered. 

IV. Finally Incarceration of the uterus occurs. Here the 
symptoms of obstruction in the pelvis gradually grow worse. 

1. Bladder — Because of the dislocation of the urethra, and press- 
ure on it, dysuria, then retention, later bladder overflows, ischuria 
paradoxa. Every case of dribbling of urine in pregnancy demands 
a local examination. Each time a little urine is passed there is great 
pain. Bladder may reach m size that of a uterus at term. Urine 
dams back into kidneys and may produce uremic symptoms. 

2. Rectum — Compression causes constipation, later vomiting, 
even ileiis. Tympany sometimes great. Patient may die of ileus 
unless cause is removed. Attended with pains at bowel movement. 
Pain in back and belly and feeling of great weight in pelvis. Even 
now there are the following terminations : 

1. Spontaneous rectification. 

2. Abortion — even when the uterus is upside down. 

3. Inflammation (may be primary) of the uterus takes place; 

all the symptoms are exaggerated ; a septic, bloody. 



NOTES ON OBSTETRICS—SENIOR CEASS. 287 

serous discharge comes from the cervix. There are 
pain and symptoms of peritonitis. The sepsis gains en- 
trance from the bladder, direct infection, or during abor- 
tion, as the septic urine may be the cause. Perforation 
of the uterus. 
The abdominal muscles contract and may force the fundus down 
on to the perineum. Rare case, the anus opened and the fundus 
with small parts appeared, also rupture of the vagina and the uterus 
has been delivered naked through the rent. 

The most important symptom is the retention of the urine. If 
this occurs very slowly the bladder hypertrophies. If retention per- 
sists and catheterization is necessary, or even without this, — cystitis 
usually results. Rupture of the bladder may take place, or rupture 
of the mucous membrane. Then the urine extravasates behind the 
mucosa and may finally separate it completely from the muscularis. 
Or the constant distension of the bladder causes anemia of the mu- 
cosa, which necroses. This anemia is aggravated by pressure of the 
cervix against the base of the bladder. The necrotic mucosa may be 
extruded per urethram. The necrosis becomes gangrene when in- 
fected, which may come from bowel adherent to the bladder, or from 
catherization. Bacterium coli communis. 
Death results — 

1. From exhaustion, sometimes after reposition. 

2. Uremia. 

3. Ileus. 

4. Sepsis, w^hich may come from gangrenous cystitis, rupture 

of the bladder, peritonitis ; may be due to the attempts 
at reposition, infection of the uterus. Sepsis the usual 
cause of death. 
Diagnosis — Usually easy. 

1. History — Pregnancy — symptoms. 

2. Abdominally — Feel the distended bladder, elastic and fluctu- 
ating, but may be hard, especially if the walls are hypertrophied. 
Alay feel like a fibroid (rare). Must always catheterize the patient 
after first noting the conditions. Neoplasm is shut out by careful 
application of the diagnostic means. 

3. Vaginally — Cervix pressed up against or above the pubis. 
Cul-de-sac filled by a large soft tumor. May feel small parts in it. 
x\fter emptying the bladder can feel no tumor abdominally, the 
hands come together with the cervix between and a sharp angle is 
felt between the cervix and fundus. If there is great pain in the 
posterior fernix, or if the question of extra-uterine pregnancy in the 
cul-de-sac or a hematoma, or an incarcerated fibroid or ovarian 
tumor comes up, it may be necessary to give chloroform. 

These are all differentiated bv the demonstration of the uterus 



288 NOTES ON OBSTETRICS—SENIOR CLASS. 

on another place. The history of course must not be forgotten in 
these cases. 

Treatment of All Cases. 

1. Empty bladder. Catheterize. Silver male catheter, if rubber 
unsuccessful. Place patient in Sim's position. Urethra usually 
drawn to one side — knee chest position. Push cervix away from 
bladder with two fingers in vagina. Take plenty of time and be 
extremely gentle. If this not successful, though it usually is, aspi- 
rate the bladder, if there are no signs of gangrene. In cases where 
the retention has been prolonged and great, let the urine oft" very 
slowly — make an interval. Reason — 

(i) Shock from sudden emptying. 

(2) Sudden rush of blood to anemic parts may cause hemor- 
rhage or gangrene. 

2. Rectum — Give saline cathartics or glycerine enema. Never 
large enemata because of rupture of the bowel. 

3. Reposition — If the uterus is not incarcerated, position may 
suffice. Morning and evening patient should get in knee chest posi- 
tion and let air into the vagina. Stay five minutes. The physician 
m.ay aid this by pushing the uterus up with the fingers, while the 
patient is in this posture. Examine again in a week to see if it has 
gone back. If it has repeat procedure and retain by a balloon pes- 
sary. Keep side position in bed. Bowels open, bladder free. Keep 
pessary until after the fourth month, then remove. 

If incarcerated, the uterus cannot be replaced so easily. Sim's 
position or knee chest, anesthesia, push fundus up, push cervix 
down, may be with vulsellum. Always push fundus to one side, to 
avoid the promontory. Not too great force because one may rup- 
ture the uterus, or adhesions, or the bladder. Death has been the 
result of too violent eft'orts. Watch her after reposition because 
bladder necrosis may occur. 

If reposition is impossible, one may temporize a short time, if 

the bladder is regularly emptied and there are no signs of cystitis 

or gangrene (Duehrssen). While waiting the writer would advise — 

(i) Knee chest position everv four hours, admitting air into 

the vagina. 

(2) The use of a colpeurynter filled with 16 oz. of water. 

(3) The use of a colpeurynter filled with mercury, first one 

pound, increasing gradually. Elevate foot of the bed. 
If this does not succeed, before inducing abortion 
laparotomy has been recommended. The writer sug- 
gests posterior colpotomy first, letting air under the 
uterus, then attempt at reposition. 
If there is gangrene of the bladder laparotomy is contra-indi- 



NOTES ON OBSTETRICS—SENIOR CLASS. 289 

cated and abortion is almost always necessary. Abortion is done 
by some when the uterus cannot be replaced by manipulations. 

May be unable to pass a bougie into the uterus. Try a steel male 
urethral sound. If this is impossible, aspirate the ovum through 
the posterior vaginal wall, with a thin exploring needle. Little risk 
if aseptic procedure. 

Aft£r the uterus is reduced in size reposition may be possible, 
or one can now induce the abortion by dilating the cervix, etc. 

Emptying of the uterus must be complete because of the bad 
drainage. If impossible to do abortion, posterior colpotomy, empty 
uterus, suture; or total extirpation of the uterus, especially if there^ 
is inflammation of the organ. 

When gangrene of the bladder has occurred, the bladder should 
be laid widely open from the vagina. If there is infiltration of the 
abdominal wall, sectio alta, with through and through drainage. 
Urotropin. 

Treatment — The treatment of partial retroversion or ^exion is 
the same. As these cases advance further in pregnancy mechanical 
difficulties in delivering the fetus may arise. Version and extrac- 
tion is the best way, but if the conditions are held well in hand, the 
vaginal Caesarean section might be the best operation. 

THE INFLAMMATIONS. 

Pelvic peritonitis rarely occurs during pregnancy. Acute and 
chronic. Acute from infection, especially criminal abortion, per- 
foration, escape of pus from a tube or appendix, rupture of the 
uterus, etc. Treatment the same as in other conditions. Must 
empty uterus in abortion cases even if symptoms of peritonitis are 
present. 

Appendicitis — Symptoms, diagnosis and treatment same as in 
non-pregnant state. 

Chronic pelvic peritonitis, or its relics, adhesions, not rare but 
not common. Pains referred to pelvis, sometimes displacements of 
the uterus, with increase of the sympathetic disturbances. Pain 
may be so bad that the patient is bedridden and needs narcotics. 
Old puerperal infection, or pelvic inflammation from any source, 
appendicitis, proctitis, etc., are causes. Missed labor said to be due 
to this condition. 

Treatment — Rest when pain is severe. Abdominal binder. 
Stimulating liniments to abdomen. Full warm baths. Laxatives, 
and if absolutely necessary, narcotics. 

Metritis — This is still, more rare ; sometimes due to infection, e. 
g., from the bladder in retro-flexio uteri gravidi incarcerata, some- 
times from extension from inflammation of neighboring organs ; 



290 NOTES ON OBSTETRICS—SENIOR CLASS. 

sometimes from infection from criminal abortions. So-called rheu- 
matism of the uterus is difficult to prove. More likely that this is 
an endometritis (see later). Perhaps circumscribed inflammation 
of the uterine muscle may explain those cases of rupture of the 
organ during gestation or labor, (Schroeder.) 

Chronic metritis is carried over into pregnancy and causes, 
sometimes abortion, pain and other discomforts during the period. 
The "irritable uterus" of the older writers may be chronic metritis. 

DISEASES OF THE DECIDUA. 

These diseases play an important role in the pathology of obstet- 
rics. Many minor irregularities in the course of labor and especially 
the third stage can be referred to an endometritis existing before 
pregnancy. 

Endometritis decidua can develop during pregnancy, however. 
The causes of endometritis in general are quite numerous. Gonor- 
rhea plays an important role. Noeggerath, in 1872, wrote a paper 
which has been authority till now, that gonorrhea is not curable for 
several, years ; that it is communicable even at the end of two years. 
Irregular living; immoderate dancing, chilling at the menstrual 
periods, sexual excesses, frequent childbirth, a slight infection or 
retention of membranes or a piece of the placenta. The decidua is 
not completely cast off and a new mucous membrane is not formed 
as it ought to be. 

Most frequent causes are gonorrhea and abortion. Abortion is 
both cause and effect. First, it may be the cause and later the endo- 
metritis may cause repeated abortions, a circulus vitiosus being es- 
tablished. 

A latent infection of the mucous membrane of the uterus may 
persist for a long time. Albert (1. c.) brings conclusive proof of 
this. 

Acute Endoinetritis Decidua — This occurs almost always in in- 
fectious diseases, such as variola, scarlatina, typhoid, cholera, trau- 
ma and infection from criminal abortions. 

The decidua is infiltrated with small hemorrhages (may be 
large ones), is thickened in places. White blood corpuscles are 
present in large numbers and one may discover various germs. 
Leads in the large majority of cases to abortion. If due to infec- 
tious diseases the germs may be found in the blood and tissues of 
the fetus. The fetus dies of the disease and then abortion occurs. 

If the disease does not cause abortion it may cause disturbances 
in the nutrition of the fetus. Occasionally blood and fleshy moles 
are formed. 

Chronic Endoinetritis — This is much "more common, and is verv 



NOTES ON OBSTETRICS—SENIOR CLASS. 291 

varied in character. Pathologically there are many varieties, but 
clinically we distinguish three : 

I. Chronic Endometritis Decidua Interstitialis. 
II. Chronic Endometritis Decidua Glandularis, 
III. Chronic Endometritis Decidua Syphilitica. 

The results of these three are — 

1. Sterility (relative). 

2. Frequent abortion. 

3. Abnormal position of the ovum, shown by the position of 

the placenta. 

4. Inflammatory adhesion of the placenta and membranes. 

5. Thickening and retention of the decidua. 

6. Abnormal formation of the placenta, shape, thickness, 

size, 

7. Retarded development of the fetus. 

In the first of these varieties the interstitial tissues are involved. 
The decidual cells increase in size ,and number, numerous white 
blood corpuscles can be seen between them, the surface may be 
rough and irregular, from irregular growth, or even a polypoid con- 
dition may occur. This is especially true when hemorrhages occur 
in the membrane, as they so often do. Xo membrane in the body is 
so disposed to hemorrhages as is the decidua. 

This thickened, hypertrophied, tubercular form of the disease is 
called Endouictritis Decidua Polyposa. 

Virchow described it and milder forms of it are not rare. The 
thickening is not marked at the sides of the uterus, in the corner 
between anterior and posterior walls. Here, on expelled portions, 
can be seen the openings of the glands. 

S^yuiptoiiis — During pregnancy : pain in the uterus, aggravation 
of the sympathetic symptoms of pregnancy, especially hyperemesis, 
painful contractions of the uterus, so-called rheumatism of the ute- 
rus, tenderness, malaise, sometimes slight fever, early interruption 
of the pregnancy. Sometimes there is a bloody mucous discharge, 
which makes one think of abortion. 

The importance of the affection depends on the location, extent 
and time of the occurrence. If the decidua serotina is involved, 
early death of the fetus and abortion; if mild, perhaps adhesion of 
the placenta in the third stage. If great in extent, abortion occurs, ^ 
or'the ovum is changed into a fleshy or bloody mole. The earlier 
the disease manifests itself, the greater the changes and the more 
the likelihood of abortion. Endometritis causes placenta previa, and 
premature detachment of the placenta. If late in pregnancy or mild 
in charact-er, it may only interfere with the third stage, e. g., slightly 
adherent placenta and membranes or pieces of thick decidua which 



292 NOTES ON OBSTETRICS—SENIOR CLASS. 

give rise to oozing of blood. These pieces of decidua may have to 
be scraped off because they cause too great a loss of blood, or they 
may come away in the puerperium, causing profuse, sometimes 
fetid, lochia, and prolonged, slowed involution. 

On the placenta the evidences of endometritis are, thickened 
serotina, which may be quite opaque and ragged in places ; vascu- 
larization of the margin of the closing plate of Winkler, which may 
extend some distance under the membranes. 

The material surface may be rough, sometimes hard, and there 
are numerous white infarcts. The contour of the placenta may be 
irregular — ^^as if it grew easier in one direction than another; there 
is a tendency to the formation of placenta succenturiata, and placen- 
tula succenturiata, also velamentous insertion of the cord. 

Diagnosis — The diagnosis may be suspected during pregnancy, 
but even when the symptoms are present, as given, a certain diagno- 
sis may be made only post partum. If the condition is suspected, 
appropriate treatment must be instituted for the pievention of the 
evil effects, e. g., placenta previa, premature detachment of placenta, 
post partum hemorrhage, premature labor. 

Treatment — General plan if patient has endometritis in preg- 
nancy, to give alterative tonics, e. g., HgCl2 1/50 gr. t. i. d., or 
arsenic gr. 1/50. Rest in bed, especially at menstrual periods. 
Symptomatic treatment. 

II. Inflammation affecting the glands. This disease has re- 
ceived another name from its most prominent symptom, i. e., a peri- 
odic discharge of watery fluid from the uterus ; Hydrorrhea Gravi- 
darum. 

Cause — The cause of Hydrorrhea Gravidarum! is very obscure. 
Gonorrheal inflammation of the endometrium cannot always explain 
it. It is due to a catarrhal endometritis, the secretion accumulating 
between the deciduae before their fusion. It is a yellowish, serous, 
sometimes bloody, fluid. 

The fluid comes more or less periodically, may be in gushes or 
dribble away. Sometimes a large amount accumulates behind the 
mucous plug between the two deciduae and suddenly gushes out. 
May simulate an abortion and is often thus explained, or this may 
even provoke an abortion, or premature labor (rather the latter). 
Occurs usually at the fourth month and then the fifth month. Some- 
times in the later months 16 oz. may accumulate, and its expulsion 
may stimulate the uterus to action, or there may be a constant drib- 
ble. Might think B. O. W. ruptured. 

Diagnosis — Lies between — 

1 . Escape of liquor amnii ; 

2. Collection of fluid between amnion and chorion ; 

3. Hydrorrhea Gravidarum. 



NOTES OX OBSTETRICS—SENIOR CLASS. 293 

In the first, labor follows, while in the second the labor need 
not follow. The accumulation of fluid between the two membranes 
seldom occurs till labor. Hydrorrhea Gravidarum cannot be dis- 
tinguished from abortion with rupture of the fetal sac. Must treat 
the case as a threatened abortion and wait. 

Treatment — Prophylactic. Endometritis — Blood tonics, HgClg 
As. During pregnancy rest, but not too much in bed. 

III. Syphilis of the Endometrium — If the mother be syphilitic 
the changes are most marked in the decidua serotina; gummatous 
growths that stretch up between the cotyledons. Also inflammation 
of the decidua vera, and degeneration of the epithelium of the pla- 
centa materna. If the father alone is syphilitic, the changes are 
limited to the fetal placenta, the villi, q. v. 

There is a purulent endometritis in pregnancy and also a gonor- 
rheal with secondary infection. 

At this point would enter a consideration of abdominal tumors, 
in their relation to pregnancy, but the time is too short for their 
consideration. 

DISEASES OF THE OVUM. 

There are many conditions which affect the child in utero. The 
acute diseases of the mother influence the child more or less ; the 
fetus has been known to have measles, smallpox, malaria, scarla- 
tina, erysipelas, sepsis, typhoid, rheumatism, recurrent fever, yellow 
fever, pneumonia, etc. The fetus may have endocarditis and peri- 
carditis, inflammation of all of the serous membranes, which may 
produce hydrocephalus, ascites, etc. ; diseases of the nervous sys- 
tem, atrophy, sclerosis, e. g., skin diseases, e. g., ichthyosis, alopecia, 
elephantiasis, etc. ; tumors of all kinds in all the organs, malignant 
and benign; it may suffer injury from without, may be so cramped 
by lack of room that it has shortening of muscles, e. g., wry neck. 
Spontaneous fractures are said to occur, from brittleness of the 
bones, without any of the usual causes, as syphilitic osteochondritis, 
rachitis. Luxations occur, which must be distinguished from those 
due to trauma during labor. Intra-uterine amputations are ob- 
served, due to amniotic bands, "Simonart's bands," to spontaneous 
gangrene (rare), to fracture, circular cellulitis (dubious). The am- 
putated part may float free in the liquor amnii, or be attached by a 
slender filament, or, if the process occurred early, may be absorbed. 

The child is affected by the blood state of the mother. The 
writer delivered a premature infant, of a mother the subject of 
chronic anemia. The infant had a large spleen and hemorrhagic 
diathesis. 

Ballantyne tries to treat the child through the mother for dis- 
ease, e. g., hemophilia. Syphilis is thus treated. 



294 NOTES OX OBSTETRICS—SEXIOR CLASS. 

Fever has a bad effect on the fetus. Runge made experiments 
in this Hne and found that if the temperature of the mother is 
raised slowly, the fetus could stand up to 105, but if it were quickly 
raised, the fetus died and often the mother. The danger, clinicalh', 
is slight because sudden rises are unusual. The child tolerates pro- 
longed high temperature well, as was shown in a case of the au- 
thor's ; where a patient had typhoid with much fever for two' months 
without effect on the fetus. 

The influence of jaundice is variable. ]\Iost often the fetus is 
not colored. If the icterus be of the grave variety, almost always 
the infants are still-born or die shortly after birth. 

Toxemic mothers, especially if eclamptic, are likely to lose their 
children. Of eclamptic cases 50% of the children are lost, either 
during or shortly after birth. Causes, toxemia, interference with 
placental circulation by stagnation of the blood current, the general 
hypercarbonization and de-oxydation of the blood, dislocation of the 
placenta, and lastly the drugs given the mother to cure the disease, 
or a combination of these causes. 

The death of the mother of course influences the child, and the 
length of time elapsing, as well as the disease from which the 
mother suffered are the determining factors. If the mother died of 
toxemia, or eclampsia, heart disease, or anemia, the fetus usually has 
died first, but if she is dead of an accident, the fetus may live a con- 
siderable number of minutes. From five minutes to two hours is 
the time given by various authors. 

Impressions on the mother's mind have been accorded strong in- 
fluence in producing organic changes in the fetus and peculiarities 
of temperament. There are those who say that such influences are 
impossible, basing reasons on — 

1. No one ever proved nerves to exist in the umbilical cord. 

2. The same deformities exist in the lower animals. 

3. The time at which the causative shock took place is usu- 

ally at a period of fetal development when the bodv is 
completely formed. 

4. Nearly every pregnant woman has nervous shocks and 

fears, and the number of deformities is small. 
On the other hand examples occur of severe nervous shock dur- 
ing pregnancy followed by such physical and mental deformities 
that something: more than a mere coincidence must be assumed. 



'fe 



TERATOLOGY. 

Congenital deformities are not rare. If the deformity is marked 
the fetus often dies early. Careful inspection of aborted ova shows 
many not even capable of intra-uterine existence. If the deformity 



NOTES ON OBSTETRICS—SENIOR CLASS. 295 

is marked, interfering with the general development of the infant, 
it is called a monster. 

Of monsters there are single and donble. 

Of the single monsters we distingnish three kinds — 

1. Monstra per defectum — where whole or part of an organ 

is missing ; 

2. Monstra per fabricam alienam — where the organ is 

wrongly developed or out of place ; 

3. Monstra per excessum — where an organ is enlarged or 

duplicated. 

Theoretically, monsters are produced — 

1st. Because there is a primary heredity, through the ovum 
or through the spermatozoid, called impetus of 
growth ; 
2nd. From a primary pathological variation of the germinat- 
ing ovum ; 
3rd. Through the influence of exterior agencies. 

The first two are called internal, the third external, causes. The 
internal causes are usually productive of typical deformities. The 
mechanism is explained by the assumption of a primary variation in 
the mode of growth of the ovum, the result of an imperfect ovum 
or an imperfect spermatozoid, or imperfect fusion. 

Heredity plays an important part, as we see the same deformity 
appear in father and child or mother and child. Sometimes a gen- 
eration is skipped and the deformity reappears in the third ; this is 
called atavism. 

External Causes — These are much more frequent and easier 
understood. Pressure on the fetuS; e. g., oligohydramnion, may cause 
deformity because the child cannot move the extremities, club foot 
and hand are evidences of this. Shock to the ovum, disturbance of 
its circulation, through hemorrhages in the decidua, infectious dis- 
eases, endometritis, may all cause abortion. Especially do patho- 
logical conditions of the amnion cause single monsters. Adhesion 
of the young embryo to the amnion, inflammation of the amnion 
and later adhesion, insuflicient development of the head, or of the 
tail fold of the amnion (hmders the development of the head or of 
the breech and the extremities), and finally, abnormalities of the 
amnion are usually coincident with absence of closure of the thorax 
and abdomen, though the former is not necessarily causative of the 
latter. 

The earlier, the action of the noxious influence the greater the de- 
formity. Most of the real deformities are fully developed before 
the end of the third month. 

Monstra Per Defectum — If the deformity is great the fetus dies 
early, abortion occurs, or a mole forms. This mole may be bloody 



296 NOTES ON OBSTETRICS—SENIOR CLASS. 

or fleshy, all traces of the fetus may have vanished, it being ab- 
sorbed. Or, after the fetus dies, the membranes, the chorion espe- 
cially, continues to grow and becomes a hydatidiform mole. If later 
in the existence of the embryo, it mummifies or calcifies. If the 
cause is a general one, affecting the fetus in all parts, a dwarf is the 
result. One of the most common of this class of deformities is the 
absence of closure of the medullary canal, which may be due to 
primary agenesis, or aplasia of the medullary canal, to early hydro- 
cephalus, or hydrorachis, or to adhesion of the delicate, new-formed 
medullary- canal to the amnion. The deformities resulting from this 
are grouped under the name Cranio-rachischisis. The splitting 
may be partial, either involving only the cerebral vertebrae, when we 
have cranio-schisis, or only the spine, rachischisis. If all of the struc- 
tures covering the medullary 'canal are missing, the back presents a 
smooth, shining groove with or without traces of brain, or spinal 
cord. If only the bony arch is missing, we have a meningocele, or 
hernia cerebri, or hernia spinalis, spina bifida. 

When there is a mass of brain more or less large, we call the 
condition Acraniu; when all the brain is missing, Anencephahis. If 
the cranium is closed but smaller than normal, it is called micro- 
cephalus. 

If the anterior cerebral vesicle does not divide, we have a 
Cyclops developed, or a cyclocephalus. 

Irregularities in the closing of the branchial clefts produce de- 
formities about the face and neck, the simplest of w-hich are hare 
lip, and the severest may show absence of large parts of the face. 

The anomalies resulting from deficiency of closure of the lateral 
plates of the body walls, are, hernia umbilicalis, hernia abdominalis, 
ectopia vesicae, ectopia cordis, etc. These are grouped under the 
name Thoracogastroschisis. 

The splitting may go so far as to involve the intestine, showing 
that the two layers of the celom failed to fuse. Absence of fusion 
of the lateral halves of the genital and urinary organs produces 
deformities here, of utmost variety. Hypospadia is the mildest and 
most common, ectopia vesicae wath split pelvis more marked de- 
formity. 

Agenesis of the extremities, fusion of the extremities, or of 
fingers and toes, and deformities due to amniotic bands, occur, but 
are rare. 

II. Monstra Per Fabricam Alienam — Are mainly cases of situs 
inversus viscerum, abnormal position of the kidneys, testicle, colon, 
and sometimes of the joints, congenital luxations and deformities. 
These latter are not seldom in the first class. 

III. Monstra Per Excessiim — Increase in the number of a part 
or organ, and increase in the size of same. 



NOTES ON OBSTETRICS—SENIOR CLASS. 297 

Double Monsters — Double monsters come from one ovum, and 
are developed from one germinal vesicle. Two germinal spots may 
be formed, or two primitive streaks, or two medullary grooves, or 
later on a duplication of one or other end of the germinating zone 
takes place. 

If two embryonal spots appear, it is possible that either two 
complete individuals (homologous twins), or united twins, result, the 
two fusing as they grow. 

Cause — The cause of these monsters is unknown. Entrance of 
more than one spermatozoid not the cause ; eggs so impregnated 
die. Whether there is splitting of one primitive streak, or fusion 
of the two, likewise uncertain. Much room for study here. The 
double monsters are classified thus : 

Terata katadidyma, where the splitting is from above down- 
ward. 

Thus — 

Terata anadidyma, where it is from below — Thus : 

Terata anakatadidyma where it is both above and below — Thus : 

Homologous twins are the best examples of the last class. The 
growth of the two streaks has been undisturbed; should the split- 
ting be less complete, or should slight fusion have occurred, a double 
monster would result, of which last class the Siamese twins are a 
famous example. The specimens are named by the parts (which 
are usually homologous), that are adherent, e. g.. Thoracopagus, 
Xiphopagus (Siamese twins), Sternopagus, Kraniopagus. These 
monsters are equal in development. Those that are unequal in size, 
etc., are, fetus papyraceous, the acardiaci, the cases of inclusio fetalis, 
etc. 

The terata katadidyma are the Diprosopus, the Dicephalus, the 
Ischiopagus, the Pygopagus. 

The terata anadidyma are the Dipygus, Janiceps. See x\hlfeld's 
Plates. 

The Clinical Aspects of Monsters — Hohl, in 1850, found 55% of 
single monsters with defects of growth (m. per defectum), had to 
be treated by operation, while only 38% of the monsters per ex- 
cessum, double monsters, or those with parasites, had to be oper- 
ative. But when the latter came to operation, it was more severe 
and dangerous by far. In the former only version or extraction 
usually was necessary, while in the latter all the dangerous obstetri- 
cal procedures has to be enlisted. 

The single monsters causing dystocia are the hydrocephali, anen- 
cephalia, hemiae and dilatation of the body cavities with fluid. 

Diagnosis — The diagnosis of single monsters can often be made 
early in labor, and sometimes even before labor, and there are 
various conditions which may cause us to suspect or anticipate a 



298 NOTES ON OBSTETRICS—SENIOR CLASS. 

monster, c. g., previous labor, hydramnion, and, if a part ot tne 
fetus extruded presents a deformity, e. g., club foot, hare lip, spina 
bifida. 

The diagnosis of double monsters is very difficult, at all times, 
and impossible before labor. Though guesses have been ventured. 
At most one will diagnose twins, and when there is a stop in the 
progress of labor the whole hand will be inserted and the union 
of the two bodies discovered. 

Lyell mentions that when a head is born with hare-lip, and labor 
stops, a double monster may be suspected. Once, in a dicephalus, 
occlusio ani was observed. If in a case of twins two bags of waters 
were found, a double monster is excluded. In general, it may be 
said that the diagnosis of single and double monsters is made so 
seldom because physicians are usually so careless in their examina- 
tions of pregnant women and during labor. 

For clinical purposes the various double monsters may be di- 
vided as follows, into three forms : 

I. Those which offer obstacle to delivery by the increase of the 
size of the body at one or the other end, e. g., Diprosopus, Cephalo- 
thoracopagus, Dipygus Parasiticus, e. g., epignathus, dipygus para- 
siticus. Most of the monsters belong to the classes, terata ana and 
terata katadidyma. 

II. Those monsters where the fusion is one or the other end> 
the two having the tendency to form a straight trunk, ischiopagus, 
pygopagus, craniopagus. 

III. Where the monsters 'are well formed and have freedom of 
motion at the point of fusion, e. g., thoracopagus, xiphopagus, or 
where there are two or three heads, well developed on one trunk. 

Treatment — In general, breech presentations are more favorable 
for all monsters, and if double, best if all four legs present. The 
exception is the ischiopagus, but here usually there is no difficulty. 
If a hydrocephalus, puncture with trocar, never forceps ; in other 
single monsters, if an indication arises to terminate labor, version 
followed by extraction, wherever possible. The wTiter holds that 
whenever a monster is positively diagnosed, no consideration should 
be shown the child or children. If the labor can be completed with- 
out added dangers to the mother, and the children delivered whole, 
this course is decidedly preferable, but there must positively be no 
added danger. As a general rule, it is not a good plan to amputate 
a part that is already delivered. Although it may give a little more 
easy access to the genitals, this is not always needed, and, on the 
other hand, the removal of parts interferes with the mechanism of 
labor and destroys the relations of one to the other, so that com- 
plications are usually added. This is certainly true of the removal 
of extremities. It is also true in the treatment of interlocked twins. 



NOTES ON OBSTETRICS—SENIOR CEASS. 299 

I. The monsters clue to fission at either end. If the head does 
not engage, version and extraction. If impossible to dehver, perfora- 
tion and cranioclasis. If the fusion is from below, extraction on 
all the legs that there are. Seldom possible to extract on part of the 
number. In doing a version with this class of monsters bring 
down all the legs. Seldom necessary to amputate parts to deliver 
breech. 

II. The end to end monsters almost never give trouble. One 
case on record where they bent double like the letter U. Other times 
they slip out easily. 

III. Of the last class, the Siamese twins give a good example. 
If in such cases the feet present, or can be* brought down, the ex- 
traction should thus be done. Deliver the posterior child first, then 
the anterior. If the heads present, version of both; if this is im- 
possible, bring head of one down and deliver, then turn second^ 
bringing it out by breech. If this is impossible, deliver one, embry- 
otomy, then on the second. If the case is a dicephalus, deliver one 
head, then try to turn and extract trunk, then, lastly, the second 
head. If not possible, remove delivered head and then turn balance 
of monster. 

Great care must be given to the kind of monster one has to 
deal with, as this has much influence on the treatment. The whole 
hand must be inserted, under anesthetic, and the case then thor- 
oughly worked out before operating. 

DISEASES OF THE FETAL ENVELOPES. 

The chorion is rarely diseased. It is not seldom thickened. It 
is sometimes tougher than at other times. Two well-defined patho- 
logical conditions affect it. First, more common, a vesicular de- 
generation ; and second, quite rare, fibromyxoma. 

Vesicular or hydatidiform degeneration of the chorion, or vesicu- 
lar mole, occurs i in about 2,000 cases. It is a hyperplasia and 
mucoid degeneration of the chorionic villi. The villi enlarge, grow 
in all directions unequally, multiply and sometimes fill the uterus to- 
the size of a man's head. The villus may thus grow to the size of a 
pin-head or to that of a hen's Qgg (rare). Usually they are the 
size of a pea or bean. The mass looks like a bunch of irregular-sized 
grapes, and is, therefore, called grape mole. Microscopically, the 
vesicle consists of an inner, lightly cellular mass, full of thin mucoid 
fluid (altered jeUy of Wharton), surrounded by a thin capsule hav- 
ing an inner fibrous layer and an outer cellular layer, said to come 
from the exochorion. If the fetus is dead there are no blood ves- 
sels, but if alive there is a fine capillary network in the degenerated 
villi. The mass is seldom expelled entire, but w^hen it is, is covered 



300 NOTES ON OBSTETRICS—SENIOR CLASS. 

more or less completely with decidua. There is more or less decidua 
between the vesicles, giving the mass greater or less marked con- 
sistency. The process may have come to a standstill, hemorrhages 
have occurred in the mass, and it is more compact, more or less 
organized. Sometimes all the ovum is changed; this, when the 
degeneration begins early, before the chorion laeve has atrophied ; if 
later, only the placenta is affected. All the placenta or only a part 
may be affected. Sometimes a few vesicles will be found on an 
aborted ovum. One twin ovum may thus be degenerated, the other 
healthy. The fetus sometimes is completely absorbed, or it may 
present more or less macerated, or even (rarely) be alive. The de- 
generation may, if it occurs early, cause the death of the fetus. Also, 
the death of the fetus may cause the degeneration. 

Etiology — Actual exciting cause unknown. Absence of the allan- 
tois, absence of vessels in the same, stenosis of the umbilical vein — 
all have little to convince. The disease may be the result of changes 
in the fetus and in the mother. That the first is true we may think — 

(i) Because one of twins may be affected. 

(2) Because aborted ova not seldom show a mild degeneration 
of the chorion, not enough to kill the fetus, and, therefore, we sus- 
pect the death of the fetus caused the former. On the other hand, 
there must be maternal influence because — 

(i) It may occur over and over again (one woman 11 
times). 

(2) Certain pathological conditions often coexist, endo- 

metritis, myomata. 

(3) A part of the placenta may degenerate and the fetus nor- 

mal. 

The disease occurs oftener in multiparae than in primiparae ; it 
may occur as late as the 52nd year and as early as the 9th year, 
usually after the 25th. Syphilis has nothing to do with it. It may 
occur with general anasarca. 

Course of the Disease and Diagnosis — The symptoms will sel- 
dom allow a positive diagnosis. Hemorrhage is usually the first 
symptom, or a bloody serous discharge ; very rarely are vesicles 
found. The blood has less tendency to clot. The uterus grows 
large rapidly, not corresponding to the time of the pregnancy ; it 
feels different from the normal pregnancy, one cannot feel fetal 
parts. Sometimes it grows so rapidly that symptoms of distention 
of the uterus may appear. The uterus does not feel like a healthy 
pregnancy. Nephritis is not an infrequent complication. 

Terminations — 

1. Abortion becaus.e of the death of the fetus or overdistention 
of the uterus. 

2. Such severe hemorrhage that the physician interferes, or pa- 



NOTES ON OBSTETRICS—SENIOR CLASS. 301 

tient may die from hemorrhage, which may be external or internal 
(into the peritoneal cavity). 

3. Vesicles may burrow into uterine wall, or through it, causing 
hemorrhage or rupture, or may degenerate into malignant syn- 
citioma. 

The condition, therefore, is formidable. The main points in the 
diagnosis are : 

1. The discharge of watery fluid with blood, the rapid and ir- 
relevant enlargement of the uterus with a peculiar consistency. 

2. The discharge of vesicles or their palpation per the os. 
Prognosis — Maternal mortality given as 18%, therefore guarded; 

remember the terminations. 

Treatment — Has great effect on the mortality. No time foi 
temporizing after a positive diagnosis is made, but empty the uterus. 
Otherwise, the usual treatment of abortion. In cleaning out the 
uterus be careful not to puncture the wall, because it is often thinned 
ui places. Death has thus occurred. Careful to remove everything 
so that nothing is left to become malignant, or septic, which give 
added dangers. 

Myxoma diffusum. Myxoma fibrosum. 

DISEASES OF THE PLACENTA. 

Anomalies of size — Normal 500 gms. May be 1,700 gms. ; large 
fetus, usually large placenta. It seems that the chorion may keep 
up its vascular connection with the mother and grow further. Some- 
times a large placenta occurs in hydramnion. Placenta usually 2 
cm. thick, but may be thicker. If larger in expanse it is thinner. 
Sometimes the whole periphery of the ovum is changed into a pla- 
centa-like structure, but there is no body like a placenta. This con- 
dition exists among the pachydermata, called placenta membranacea. 

Form — Sometimes the placenta is divided into several, may be 
seven, but there is usually one large placenta, and the rest are ac- 
cessory. Called Placenta Succenturiata, and are connected with the 
main placenta by blood vessels. If not, they are called Placenta 
Spuria. 

Three views as to the cause of Placenta Succenturiata : 

(a) That some of the villi of the chorion laeve develop to form 
the accessory placenta. 

(b) That a portion of the placenta is cut off by white infarcts. 

(c) That frorn some accident the decidua reflexa is missing and 
the chorionic villi find favorable conditions for growth in the decidua 
vera. 

Clinical Importance — Examine every placenta with this in mind 
and notice the distribution of the blood vessels. 



302 NOTES OX OBSTETRICS—SENIOR CLASS. 

ANOMALIES OF PLACENTA. 

Of the anomalies of the placenta the most frequent is the White 
Infarct (x\ckerman). Sometimes called Hepatization, Cirrhosis, 
Fibrin deposit, Placentitis, etc. Two theories as to their causation : 

L Ackerman's — that there is a fibrous periarteritis, which 
causes obliteration of the blood vessels and, therefore, infarction. 
(WiUiams says endarteritis.) 

IL That it is an inflammatory process of the decidua. Truth 
in both. 

L Explains the numerous small white infarcts on the fetal sur- 
face, while IL explains the larger ones on the maternal surface and 
arotmd the edge of the placenta. Sometimes we see all around the 
placenta, at a distance variable from the edge, a ring of white fibrous 
material, called placenta marginata. It is due to inflammatory con- 
ditions in the decidua ; is not rare. These placentae sometimes cause 
a slight hemorrhage before labor, and may be accompanied by re- 
tention of pieces of the chorion (endometritis). Possible that some 
of the white infarcts may be organized hemorrhages. Fehling has 
proven that white infarcts occur frequently with nephritis. May 
be due to the general arterial changes that accompany this dis- 
ease. 

That hemorrhage may occur in such a vascular organ as the 
placenta is curious, but is a fact. Thrombosis can occur in the 
maternal sinuses, and increase of the connective tissue, perhaps not 
mflammatory, can obliterate the villi in greater or less extent. 

Clinically — The clinical importance of white infarct is : 

(a) Death of the fetus. 

(b) Poor nourishment. 

(c) Later diseases. 

Hemorrhages — Occur during pregnancy, but are slight usually. 
If early, they may cause abortion ; later, they affect tlie circulation 
of the fetus to a variable degree, depending on site and extent. May 
recur, one giving disposition to another, and thus cause a prema- 
ture separation of the placenta near term. A dangerous complica- 
tion. Nearly always fatal to child, and in 40% to 55% of cases 
fatal to the mother. 

Hemorrhages sometimes occur at edge of placenta and may be 
partly organized by the time of labor, and recognized as having 
caused a partial separation of the organ, but the condition did not 
grow worse. Sometimes a clot undergoes cystic changes. 

A clot may be determined to be old by the stage of organization 
in which it is found. 

Causes — The causes of these hemorrhages are : congestion, acute 
or chronic ; renal disease, stagnation of the uterine blood current. 



NOTES ON OBSTETRICS—SENIOR CLASS. 303 

disease of the villi, of the decidual blood vessels, hemorrhagic diathe- 
sis. Acting causes are physical or mental shock, not necessarily 
severe. 

Placentitis — Merely historical interest. There is an inflamma- 
tion of the decidua serotina, but we have considered that when we 
considered Endometritis Decidua. Formerly described in three 
.stages, like a Pneumonia, but it does not exist. 

Edema — This may occur with hydramnion, interference with the 
fetal circulation, or with the maternal circulation — heart disease. 
Liver with dropsy. 

The placenta is edematous, thickened, paler, shaggy, because the 
.serotina is separated unevenly. 

Villi are club-shaped and swollen. Contour irregular. 

Atelectasis — Sometimes a placental cotyledon is completely infil- 
trated with fibrous material, solid, no intervillous spaces. Dark red 
in color; hard to the touch. Occurs sometimes in placenta previa, 
the piece overlapping the internal os has this condition and may make 
the diagnosis difficult. 

This fibrous change may be concrete, or may be somewhat dif- 
fuse, giving the placenta a fibrous character. It may, therefore, 
interfere with the nourishment of the fetus. 

Calcification — Occurs where white infarcts occur, especially in 
the upper layers of the decidua serotina. There may be a few 
calcareous granules, or the whole surface may feel sandy. Oc- 
curs especially where the anchoring villi are. They are of no clini- 
cal importance. Are composed of calcium and magnesium phos- 
phates and carbonates. 

Not syphiUtic. Not tuberculous. No indication of the over- 
ripeness of the fetus. May occur as early as 6 months. May indi- 
cate the last stage of a white infarct. Formerly believed to mean 
that the pregnancy had lasted over 280 days, but not -so. Where 
they occur in the villi, near the fetal surface, may be pathological. 

Syphilis — Syph. placentae are usually not recognized before the 
'6th month, while the changes of the fetus are marked before this 
time. Difficult to recognize syphilis on the placenta. Placenta is 
large, thick, soft, pale, whitish, heavy. Relatively heavier than nor- 
mal, whether fetus dies in utero or is born at term. If the father 
is syphilitic, the mother remaining healthy, changes are limited to 
the chorionic villi. These become swollen, club-shaped ; the vessels 
obliterated by the growth of white cells in and around them. Changes 
explain the death of the fetus, as the compression exerted by the 
cells shuts ofif the blood supply and fetus dies. Also, shuts off the 
blood of the villi so they get fatty. May be fine hemorrhages. 

If the syphilis comes from the mother the changes may be seated 
in the decidua, i. e.. Endometritis Decidua Gummosa. 



304 NOTES ON OBSTETRICS—SENIOR CLASS. 

If the mother becomes syphiHtic at the time of the impregnating 
coitus, we find on the placenta manifestations of syphilis in both 
zones of growth, the villi and the decidua. 

Syphilitic placentae are usually large and feel fatty. They may 
be adherent to the uterus and sometimes a hemorrhagic condition is 
caused. 

Cysts — Not seldom find on the fetal surface cysts beneath the 
amnion, situated in the chorion, containing a clear or yellowish 
serum. They may be from a spHt pea to an orange in size. May 
be fined with flattened epithelium. 

1. Are usually collections of Wharton's Jelly. 

2. May be due to hemorrhages in the process of absorption. 
Have no clinical significance. 

Tumors — Tumors of the placenta are very rare. Malignant de- 
generation of a polyps, the result of placental remnants, has long 
been known, and that myxomatous moles sometimes become malig- 
nant, also. Recently studies have been made which show that sar- 
comata may develop from the connective tissues of the decidua, 
stimulated to growth by pregnancy, and cancers of the syncitiumi 
covering the villi ; decidua-sarcoma, or deciduoma malignum and 
carcinoma syncitiale. 

ANOMALIES OF THE AMNION— POLYHYDRAMNIOS. 
OLIGOHYDRAMNIOS. 

Normal amount of liquor amnii is about i,ooo gms. Varies, how- 
ever, within very wide limits. Extremes, below 600 gms., is patho- 
logical ; over 2,000 gms. is pathological — Polyhydramnion. Since 
we do not know the source of the liquor amnii normally, it is im- 
possible to give a systematic Etiology of the anomalies. 

Hydramnion is more common than oligohydramnion, and there 
may be as much as 6 quarts of water in the uterus. May be fetal or 
maternal in origin. 

I. If fetal we usually find the fetus malformed. Often there 
is a sort of Amnionitis. (This is not accepted by all authors.) The 
membrane is discolored and has sometimes formed adhesions to the 
fetus, e. g., head, organs of the chest or abdomen. 

II. In other deformities, find imperfect closures of the fetal 
clefts, e. g., hare lip, hemicephalus, ectopia vesicae. The hydramnion 
is due to a transudation from the blood vessels, imperfectly covered. 
Occlusion of the gullet of the fetus which does not drink the liquor 
amnii. 

III. Diseases of the fetus, involving obstruction to the venous 
circulation, stasis and edema. Stenosis of the cord, cirrhosis of the 
liver, stenosis aortae, of the Ductus Botalli. In these cases the 



NOTES ON OBSTETRICS—SENIOR CLASS. 305 

fetal kidneys take on action and get urea in the liquor amnii and a 
large amount of urine. 

IV. Get hydramnion often with twins from one ovum. T\Iay be 
in one or both ova. If marked in one usually less in the other. 
These cases are due usually to homologous twins, where the cir- 
culation of one communicating with the other, one proving stronger 
than the other, forces an extra amount of blood into the blood ves- 
sels of the other. As a result of this, there is exudate from the blood 
vessels of the weaker twin, which may atrophy and become a fetus 
papyraceous, or an acardiacus, or its heart and kidneys may under- 
go hypertrophy and cause extra secretion of urine, thus adding to 
the causes which produce the hydramnion. 

V. Jungbluth said that the vasa propria of the chorion persist, 
therefore hydramnion. 

Maternal causes. Relatively seldom causative. 

1. All those conditions which cause general anasarca and dropsy, 
e. g., heart, liver, lung and kidney diseases. 

2. Syphilis, leukemia, chronic anemia ; but here the exudate oc- 
curs in the whole ovum, hydrops universalis. 

3. Diseases of* the placenta, e. g., syphiHs. 

Hydramnion is more frequent in multiparae than in primiparae, 
28 to 5, McClintock. 

Clinical Characters — Two kinds — acute and chronic. Only dif- 
ference being rapidity of development. 

The acute is graver and leads usually to abortion. 

Begins about the fourth month and rapidly dilates the uterus 
to colossal size. The mechanical symptoms are greatly increased. 
Pain in the abdomen, feeling of great tension, dyspnea, especially 
in primiparae, and attacks of suffocation. Vomiting or nausea 
marked. Patient emaciates and may have fever. Uterus may be 
larger than at term. Great edema of lower extremities. Symp- 
toms referable to the kidney of pregnancy or even an acute nephritis. 

Findings — Abdomen enormously distended. Uterus tense, no 
fetal parts palpable. Belly sometimes too tight and painful to get 
fluctuation. Heart tones may be inaudible. Uterus high (vag- 
inally), so that the vagina is put on the stretch upward. 

Diagnosis — If you have known the case before, it is simple. If 
called, as often happens, because the woman says there is a tumor 
in the belly which grows very rapidly, the diagnosis may be very 
hard, from rapidly growing ovarian tumor, especially when com- 
plicated wath torsion of the pedicle. The persistent absence of heart 
tones, the demonstration of intermittent uterine contractions, the 
findings per vaginam, and finally the crucial test, the uterine sound. 
Use it, since if ovarian tumor, wnll do no harm. If hvdramnion, it 



306 NOTES ON OBSTETRICS—SENIOR CLASS. 

was the treatment, anyway. Diagnosis from twins may be hard, 
but remember that it is often comphcated with twins. 

Course — Acute hydramnion usually leads to abortion or the 
symptoms get so marked that you must induce it. The fetuses die 
usually, but rarely the symptoms may subside, one fetus dying, the 
other being born at term. Not to be waited for, however, nor should 
one wait till fetus viable. Indications are danger to mother from 
obstruction to respiration, and from uremic symptoms. 

Treatment — Abortion — Puncture bag of waters, but let water off 
vei f slowly, to avoid shock. Leave the case to nature in the ab- 
seiice of further symptoms. 

Chronic Hydramnion — Differs from the acute in that it is much 
more common; does not lead so often to abortion (sometimes to 
premature labor) ; is less rapid in its course. Chronic hydramnion 
occurs oftener in multiparae, and girls seem to be found more often 
than boys. Chronic hydramnion is also found in extra uterine preg- 
nancy, which makes the diagnosis exceedingly difficult. 

Symptoms — The same, but less marked. Still, the edema may be 
great and kidney symptoms develop often towards the latter part 
of pregnancy. 

Diagnosis — Lies between this and twin pregnancy,^ most often, 
and can usually be made. Remarkable fact that although the uterus 
is tense, the bag of waters felt through the os is relaxed. Said 
that in twin pregnancy the bag of waters is tense. Perhaps this 
m.ay help in the differentiation. 

Prognosis — Depends on the cause of the disease. If maternal, 
e. g., syphilis, heart or kidney lesion, prognosis is not good. But 
if fetal, prognosis for mother good. Still, must remember that it 
can cause kidney lesions — and in labor the pains are weak, operative 
procedures sometimes needed, and tendency to atony uteri post 
partum and, therefore, post partum hemorrhage. Prolapse of the 
cord. 

Prognosis — For fetus, in acute hydramnion, is bad. In chronic 
fair, but remember the frequent occurrence of deformities which 
miay make extra uterine existence impossible. 

Treatment — Expectant; watch the kidneys carefully. If respira- 
tory or renal symptoms dangerous, induce premature labor, puncture 
bag of waters. During labor, if pains weak, puncture bag of waters, 
but let water off slowly to prevent prolapse of the cord or extrem- 
ities. Crede, in third stage. Tampon if necessary. 

Oligo Hydramnion — This is a decrease in the amount of liquor 
amnii and is very rare. The decrease may be primary, affecting the 
ovum early, and resulting in more or less adhesion of the amnion 
to the fetus. This causes deformities, e. g., hemicephalus, cranio- 
rachischis, spina bifida, amputations of extremities, club foot, etc. 



NOTES OX OBSTETRICS—SENIOR CLASS. 307 

If secondary, the decrease comes on later, and then the fetus 
shrinks up, skin is dry, no panniculus adiposus. At the labor a few 
tablespoonfuls of thick, yellow-green liquor amnii. 
Nothing is definitely known about the etiology. 
Clinically of no importance. Very rarely causes dystocia. 

ANOMALIES OF THE CORD. 

False Knots — The vein is longer than the arteries, and both are 
longer than the cord, therefore the vessels must be twisted and the 
vein is twisted more than the arteries. Where a vessel forms a loop 
the jelly of Wharton is sometimes thicker. This makes a marked 
lump on the cord, and is called a "false knot." Have no practical 
imiportance. 

Short Cord (Abnormally) — Cases where the fetus is applied to 
the placenta, and there is no cord at all, are very rare. They usual- 
ly are complicated with an umbilical hernia. From this the cord 
varies up to the length of six feet. The causes of this anomaly are 
not known. 

Clinically — Cords are either absolutely too short, or relatively, 
e. g., when there are several turns around the neck or extremities. 
If too short, they may cause delay in labor. If the pains are strong, 
the child may be extruded, and the cord tear off the baby, or off the 
placenta, or tear the placenta from the uterus. In either case, there 
is danger of asphyxia. In the last case, danger to the mother from 
intrauterine hemorrhage. 

Diagnosis — Treatment — 

Forceps is sometimes necessary when there is delay in the 
labor; in general, too short cords are rare, and usually terminate 
safely. 

Abnormally long cords are not common. The average is 60 cm. 
(about 24 inches), but there are some reports of cords of 60 inches, 
and even 10 feet. x\side from the danger of prolapse and coiling 
around the fetus, they do not possess any clinical importance. Even 
very short cords can prolapse and often long ones do not, even if 
given proper conditions. 

Coiling — Coiling of the cord around the parts of the fetus has 
slight significance. If around the neck, sometimes the coils may be 
so tight as to impede the return circulation from the head. Said 
that atrophy or hydrocephalus is the result. 

The frequency of coils around the neck at labor is i to 4. Ex- 
plained thus : There is a coil of cord at the bottom of the uterine 
sac and the head, in advancing, goes through the loop. Further, 
the active fetal movements cause coils. If the coil gets around the 
neck early in pregnancy, it may kill the child — then abortion. 



308 NOTES ON OBSTETRICS— SENIOR CLASS. 

The cord does not cause amputations of the extremities in utero, 
because sufficient pressure to do this would cut off the circulation in 
the cord and kill the fetus first. Sometimes the coiling of the cord 
around the neck may be diagnosed by the fetal souffle. 

Torsion of the Cord — Quite frequent. As a cause of death, very 
seldom. The torsion may affect the whole cord. As many as 380 
turns have been counted. They may even twist the skin of the 
fetus. They are due to the movements of the fetus. Or the torsion 
may be in one place. In either case, the vessels are occluded or 
compressed, and the death of the fetus may be the result. Called 
stricture of the cord. Of course, the torsion may occur after the 
fetus is dead, and it is probable that a large number of the cases 
are due to this. Especially likely in macerated fetuses. Differential 
Diagnosis — Between twisting that occurred ante-mortem and post- 
mortem is made first by noting adhesions between the coils. Second, 
by trying to untw^ist them. In twisting occurring before death, the 
coils are fixed. 

True Knots — Not common. May be single or complicated. 
Rarely cause the death of the fetus. Due to the active movements 
of the fetus, which slips through a loop of cord. May occur dur- 
ing labor, which is more . common. Have little obstetric impor- 
tance. 

Syphilis — Syphilis of the cord is sometimes observed. Com- 
moner than is usually thought, because it is not looked for. Some 
form of endarteritis, and especially calcareous degeneration, which 
extends into the media in severe cases. May occlude vessel. Oc- 
casionally there are white infiltrated areas in Wharton's Jelly which 
resemble gummata. 

Hernia — Hernia into the cord is a rare anomaly. It may be small 
at birth, and grow because of the crying of the child. Or it may be 
complicated, with insufficient closure of the abdominal plates. The 
hernia varies in size from a minimum to the size of a child's head. 
It is covered by, first, a thin layer of amnion ; second, a more or less 
thick layer of Wharton's Jelly ; third, peritoneum. If at all extensive 
the hernia may contain liver and kidneys beside the intestine. If 
much tension is put on the mysentery, it changes the kyphosis of the 
spinal column to lordosis and may cause trouble in labor. 

Baby dies if operation is not done. Still, in rare cases, the dead 
amnion is cast off by a layer of granulations, and the part heals over. 
Otherwise, the fetus dies of peritonitis. Operation should be done on 
all these cases and as early as possible. Return the contents of the 
abdomen after dissecting off all the amnion and Wharton's Jelly. 
Freshen edges and bring together. Only successful in mild cases. 

Velamentoiis Insertion of the Cord — Is the insertion of the cord 
into the membranes more or less far from the edge of the placenta. 



NOTES ON OBSTETRICS—SENIOR CLASS. 309 

It occurs once in loo placentae. Due to abnormal adhesion of the 
allantois, which prevents the rotation of the embryo, . which brings 
the belly opposite the placental site. If the blood vessels run across 
the OS to the placenta, or alongside it, they are liable to rupture and 
compression during labor, which may cause death or severe asphyxia 
or anemia to the fetus. 

ABORTION. 

i\Iost important subject. Said that almost half of the child- 
bearing women have had a miscarriage before the 35th year. Hegar 
said that there is one abortion to eight labors ; other authors say one 
to five. Large number of abortions occur in private practice which 
are not recorded. Large number where even the patient knows noth- 
ing about it, occurring in the early months. 

Abortion is defined as the interruption and termination of preg- 
nancy before the fetus is viable. Premature labor, — same after via- 
bility but before term. Miscarriage, — term of the laity, signifying 
both. Generally considered that a fetus becomes viable after the 
28th week, i. e., the 7th lunar month. Rare cases (French) of six 
months. Sometimes see signs of life in an ovum of five months, 
but it always dies soon. Best time for induction of premature labor 
is betwen 32nd and 35th week. 

Time of Occurrence — The first three months of pregnancy show 
the greatest number, 2nd and 3rd the largest of the three. 

Reasons — 

1. Ovum not strongly attached, therefore hemorrhage can easily 
dislodge it. 

2. Ovum weak, therefore susceptible to bad influences. 

3. At the time of change of the omphalo-mesenteric to the pla- 
cental circulation, owing to a poor development of the chorion, death 
of the fetus may occur. 

4. Woman does not know of her pregnancy, therefore takes no 
care of herself. 

5. Women that want to produce abortion do it now, because they 
think it no crime before quickening, and that it is without danger in 
the first months. 

After the third month abortions are less frequent, because the 
ovum has firmer attachments, the uterus has become accustomed to 
its burden, etc. 

Causes — A study of the etiology of abortion has very great im- 
portance, 1st, because of science; 2nd, treatment; 3rd, for the pre- 
vention of further abortions; 4th, medico-legal. Therefore, in all 
cases, search carefully into the causes that produce it. More fre- 
quent in multiparae, because endometritis and displacements more 



310 NOTES ON OBSTETRICS— SENIOR CLASS. 

common in them. More frequent in the cities than in the country, — 
certainly criminal abortion is. More frequent in the lower classes 
than the upper, because of the hard life the former have, lack of 
care. Criminal abortion, on the other hand, I believe to be more 
frequent in the upper classes. Causes may be divided into fetal and 
maternal. Purely arbitrary, because the fetus comes from the 
mother. 

Fetal — Every anomaly of the fetal body or its appendages that 
may contribute to its death or diminish its vitality may cause abor- 
tion; as — 

1. Changes in the decidua, chronic decidual endometritis. ,May 
have defects in the decidual cells, or pathogenic friability of the 
blood vessels with resulting apoplexies. If these occur early, the 
fetus dies from starvation, but if later, the fetus dies of asphyxia. 
In other forms of endometritis, i. e., hydrorrhea gravidarum, the 
fetus dies from starvation, but if later, the fetus dies of asphyxia, 
fluid may set up uterine contractions. If the discharge is continu- 
ous the prognosis is better. Endometritis is also a maternal cause. 

2. Diseases of the Chorion — Hydatidiform degeneration of the 
chorion very frequently leads to abortion, especially if the placenta 
be involved ; usually attended with furious hemorrhage. 

3. Affections of the Cord — Torsion, knots, stenosis at some point, 
usually near the placenta. 

4. Causes of death in the fetal body itself, as — 

a. When the circulation changes from the omphalo-mesenteriq 

to the placental. 

b. Anomalies of growth, single and double monsters. Rather 

common in abortion. 

c. Fetus dies from insolation. Sudden high temperature of 

the mother kills fetus. Runge proved that fetus stands 
high temperature if slowly increased and intermits, but 
not if sudden and continuous. 

d. Fetus may be infected from the mother with the disease 

from which she is suffering, i. e., typhoid, recurrent 
• fever, measles, scarlet fever, malaria. Syphilis mani- 

fests itself generally later in pregnancy and kills the 
fetus in two ways : First, by the syphilitic infiltration 
of the placenta, mechanically occluding the villi ; there- 
fore, death from inanition and asphyxia. Second, the 
syphilitic changes in the fetus may kill it outright. Sel- 
dom before the 5th month. 

e. Nephritis of the mother, either from the toxemia, or. the 

urea poisons the fetus, or the fibro-arteritis at the pla- 
cental site causes hemorrhages which cut off the circu- 
lation. 



NOTES OX OBSTETRICS—SENIOR CLASS. 311 

f. Fetus may die of asphyxia when the blood pressure of the 
mother is lowered too much, e. g., from extensive hemor- 
rhage. Blood at placental site is quite stagnant, uterine 
contractions sometimes force it along. 

5. Placenta Previa — External injury, hemorrhage. 

6. All causes that cause hemorrhage in the decidua serotina, e. g., 
trauma, coitus, heart and lung diseases, alcoholism. 

We can easily see how these conditions cause the death of the 
fetus, but how does the death of the fetus interrupt pregnancy? 
(i) It is thought that after the death of the fetus the ovum be- 
comes a foreign body and the uterus tries to expel it. Not true in 
all cases, because the vascular connections are sometimes kept up 
and the chorion nourished, so that it continues to grow. If these 
connections are broken, e. g., by a blood clot, this point holds true. 
(2) When the fetus dies, the stimulation which its growth exerts 
on the endometrium falls away. Said that the growing ovum in- 
hibits the uterine contractions. In other words, the alteration of 
the endometrial reflex produced by the death of the fetus is the cause 
of the expulsion of the ovum. Holds true in cases where the vascu- 
lar connections are kept up. The time elapsing from the death of 
the fetus till expulsion varies. Usually inside of a few days, but 
it may be hours, weeks, even nine months. Seldom over two 
months. Pieces of the placenta may remain in the uterus for eleven 
months. 

Maternal Causes — We have already spoken of those maternal 
causes which act by killing the child. The causes to be named will, 
to a certain extent, be a repetition of these : 

1st. Chronic endometritis most potent cause of abortion, espe- 
cially of habitual abortion, i. e., abortion occurring with each preg- 
nancy. Acts by (a) predisposing to hemorrhage in the decidua, 
which may cause abortion either by killing the fetus or starting 
uterine contractions; (b) the endometrium is sensitive and cannot 
stand irritation of the growing ovum. 

2nd. Displacements of the uterus, — retroversion and retroflexion. 
Cannot expand enough, but here an endometritis is started by the 
chronic venous congestion caused by the displacement. 

3rd. Laceration of the cervix. Formerly much considered as the 
cause. True multiparae have more abortions, and they have lacer- 
ated cervix. Usually the concomitant endometritis causes abortion, 
— the symptoms ascribed to laceration being generally due to en- 
dometritis. 

4th. Metritis. Uterus cannot develop as it should, and then the 
"irritable uterus" of older writers. 

5th. Malformations of the uterus, double and single horned uteri, 
but not necessarily. 



312 NOTES ON OBSTETRICS—SENIOR CLASS. 

6th. Hydrorrhea gravidarum (endometritis decidua glandularis). 
Sudden evacuation of the uterus excites contractions. 

7th. Trauma, or violence. Usually an important role ascribed 
to accident, but the patient must possess the predisposition or it 
will require a severe injury to bring on the pains. In some women 
no amount of violence is sufficient. Case broken sacrum, no abor- 
tion. Another case, where a slight jar to body sufficed. Women 
almost always try to find some cause under this head. Abortion 
in primiparae often due to too much coitus. 

Of interest is the effect of operations : Usually not the operation 
but the shock and sepsis that follow that cause the abortion. Op- 
erations vary greatly. Ovariotomy has been done frequently with 
good results. Pregnancy generally is not interrupted if there are 
no complications. Formerly thought the ovaries exert an influence 
on pregnancy and each menstrual period offers a tendency to abort. 
This is doubtful. Satterly said that corpus luteum has influence in 
preserving the pregnancy. Doubtful. That the ovaries are not 
necessary for labor the cases after removal of these organs show. 
Operations on the labia and cervix have been done without disturb- 
ing the pregnancy, also extirpations of breasts. Then, again, a 
slight operation on some distant organ or extremity wall bring on 
an abortion. In judging whether or not a given injury is the 
cause of abortion there are two criteria to guide us. (i) Must 
occur immediately after the trauma. (2) The ovum must be fresh: 
and show no other cause for its expulsion. Remember this in medico- 
legal cases. Never swear that this or that causes the abortion, say 
that it is in the highest degree probable, etc. 

8th. Sudden rise m the temperature of the mother, — starts up 
uterine contractions. Acute infectious diseases, etc. 

9th. Syphilis is a freqtient cause for abortion and acts by kill- 
ing the fetus, either directly by affecting the child, or by changes 
in the placenta, or it may act by lowering the mother's vitality. 
The same may be said of tuberculosis. 

Habitual Abortion — Some women miscarry regularly in each 
pregnancy. Causes are : 

1. S^yphilis, generally in the later months, seldom before the fifth 
month. History of such cases is that each abortion occurs later than 
the last until finally a living child is born, which either presents the 
signs of syphilis at birth or develops them soon and dies. Later a 
viable child is born. This show's a gradual weakening of the virus. 
If at any time the parents are properly treated, the end of the chain 
described is reached sooner and more abruptly. 

2. Chrome endometritis, and each abortion intensifies the endo- 
metritis. 



NOTES ON OBSTETRICS—SENIOR CLASS. 313 

3. Habit. Seems that the habit once formed is kept. If a woman 
induces abortion in first pregnancy, she is Hable to abort later. 

4. Nephritis. 

Mechanism of Abortion — There are three factors involved in 
abortion.: Decidua, Placenta and Fetus. In the first six weeks the 
decidua is the important factor. The ovum is small, soft, com- 
pressible, very easily detached and slips out unobserved. The sep- 
aration of the decidua is the important part and often is completed 
with difficulty by nature. From the 6th or 8th week to 5th month 
the placenta plays the important role. The fetus is small, but the 
placenta is relatively large, often separates with difficulty, and 
gives rise to severe hemorrhage. From now until term the fetus 
is most important. The separation of the ovum takes place in the 
cellular layer of the decidua as at term. Separation begins at the 
cervix and goes to the fundus, — is especially hard in the tubal 
corners, therefore pieces likely to adhere at these points. 

First Period — In the first six weeks the whole ovum is usually 
born. The decidua covers it, and sometimes possible to distinguish 
vera and reflexa. Or the ovum just covered by the reflexa is born 
or the reflexa breaks, the ovum covered with the shaggy coat of 
villi, is born naked. In the latter cases the decidua has to be thrown 
out by another effort of the uterus, which is usually accompanied by 
hemorrhage, or the deciduae come away with the lochia, piece- 
meal. Whenever you see an ovum expelled with a shaggy coat, you 
may know the deciduae are still in the uterus. 

In the Second Period — i. e., from the 6th or 8th week to 5th 
month — the process may take two courses: ist. The whole ovum, 
fetus in the sac, and placenta, expelled. This may be called the 
typical or normal course and offers the best prognosis for miother. 
2nd. The membranes rupture, the fetus is expelled, the cervix closes, 
and the uterus has to exert a new effort to expel the secundines. The 
hemorrhage is usually profuse ; this may be called the atypical or ab- 
normal course, and offers worse prognosis because of hemorrhage, 
sepsis, operation. The uterine contractions force the ovum down 
into the cervix. This is softened and dilated from above downwards 
as in labor. Separation of the ovum from the uterine w^all and ex- 
trusion take place at the same time. In multiparae, as soon as the 
internal os is passed, the ovum slips into the vagina. In primiparae. 
the external os offers resistance and this may be enough to prevent 
the further exit of the ovum. If it be small, the cervix dilates and 
contains it, w^hile the internal os closes behind it. Called cervical 
pregnancy by Rokitansky, but better narhe is cervical abortion. 
Sometimes the ovum is too firmly adherent at some point, usually 
the corner of the uterus, and hangs down. This is usually the case 
when the membranes break. The uterus, if given time, will usually 



314 NOTES ON OBSTETRICS—SENIOR CLASS. 

separate the ovum and expel it, but it may be accompanied by such 
hemorrhage as to become dangerous, or the process may take so long 
that sepsis sets in. The hemorrhage comes from the vessels in the 
decidua or from the placental site. 

The course of abortion may be quite protracted; generally takes 
a day, but it may last hours, days or weeks. When the fetus is ex- 
pelled and part or all of the secundines are left, we speak of in- 
complete abortion. 

Third Period — Abortion in the 5th month, and later, is really a 
labor in miniature, and needs no further description. 

Symptoms — There are four chief symptoms in abortion : 

I. Uterine hemorrhage. 2. Uterine pain. 3. Softening and 
dilatation of cervix. 4. Presentation or expulsion of all or part 
of ovum. 

We divide the course of abortion into three stages : 

A. Threatened abortion. 

B. Abortion in progress. 

C. Incomplete abortion. 

In threatened abortion the main symptom is hemorrhage, which 
may come with a gush or more usually by a slight oozing of blood 
or bloody slime, may be of brown color. This may keep up for sev- 
eral weeks, or stop and recommence after weeks. Light, drawing 
pains are usually felt, or sometimes labor pains, but they are not so 
severe as at term. Sometimes pain is a very slight symptom, only a 
weight in the pelvis. Softening and dilation of the cervix slight in- 
deed. Uterus is harder than it ought to be, because it is con- 
tracting. After a shorter or longer period, which may be hours, 
days or weeks, symptoms subside and pregnancy goes on to term, 
or suddenly the hemorrhage becomes profuse and abortion occurs, 
or interference is necessary. 

Abortion in progress presents the same symptoms intensified. 
Hemorrhage more, pain greater, and resembles more the labor pains. 
The cervix begins to soften and dilate from above downward and 
the examining finger feels the ovum in the cervix or uterus. Pain 
varies greatly, perhaps a few slight pains, and the whole ovum is 
extruded, or may have real hard pains for hours. Hemorrhage 
varies also, sometimes abortion occurs spontaneously and there is 
very Httle hemorrhage, again the woman may almost bleed to death 
(very rare), with all grades between. The symptoms of abortion 
vary, of course, with the course of the abortion. 

1. If the whole ovum and decidua are expelled at once, the 
hemorrhage and pain cease and the patient recovers. 

2. If the membranes break, the fetus escaping, after a longer 
or shorter period, minutes or hours, the remainder is expelled or 



NOTES ON OBSTETRICS—SENIOR CLASS. 315 

removed by the physician. This means another period of hemor- 
rhage and pains. 

Incomplete abortion means the retention of all or part of the se- 
cmidines. In general, there are four terminations of incomplete 
abortion : 

1. The cervix closes to a great extent and what is left gradually 
breaks up and is discharged in the lochia. In these cases the lochia 
are profuse and keep up until the last bit is discharged. Chronic 
endometritis likely to follow. 

2. A complete interval of rest may occur, when the uterus sud- 
denly discharges its contents. This may be days or months. 

3. Decomposition sets in and the pieces are exfoliated, or the 
patient dies of sepsis (rare). 

4. Placental polyp is formed. What is left is nourished and be- 
comes a placental polyp, or is covered by blood deposits. Sarcoma 
deciduo-cellulare may result. 

Diagnosis — Usually the diagnosis of abortion is not difficult, 
when we know the case to be one of pregnancy, but sometimes 
necessary to diagnose the pregnancy, and this, when the abortion is 
in progress, may be hard. Everything depends upon the bimanual. 
Softening of the vagina, cervix, enlargement of the uterus. Hard 
and contracting uterus, signs and symptoms of pregnancy, but rely 
on the objective signs only. 

Rule — Treat every case of hemorrhage occurring in a woman 
capable of reproduction, after an amenorrhoea of one or two months, 
as an abortion. Seldom far out on the diagnosis. Extra uterine 
pregnancy must be considered if there is a tumor alongside the 
uterus. 

In threatened abortion, the softening and dilatation of the lower 
uterine segment are not marked, and we have only the fact of preg- 
nancy and the hemorrhage with pain to guide us. In abortion in 
progress the cervix allows the finger to feel the ovum, which settles 
the diagnosis, or can feel the ovum bulging the upper cervix. 

In incomplete abortion a polypus may need dii¥erentiation, — 
history, etc. Treatment, the same. When a woman has had an abor- 
tion and has continued irregular hemorrhages, or bloody slime, has 
a softened, enlarged cervix, a patulous external and internal os, a 
large uterus (usually hard), we call it incomplete abortion. The 
finger in the cervix may feel part of the placenta, or decidua, hang- 
ing down, or patient may say that pieces of these parts are observed 
to pass. The continued hemorrhage may cause severe anemia. Un- 
less attempts have been made to remove these parts, they do not 
usually become septic. 

Of great importance is the diagnosis of the life or death of the 
fetus. In the early months this cannot be done with certainty. We 



316 NOTES ON OBSTETRICS—SENIOR CLASS. 

think of death of the fetus when a pregnant woman has already born 
degenerated ova, has had irregular hemorrhage for some time, or 
bloody mucus, and in which the uterus is hard, round and smaller 
than at the time of the supposed preg-nancy and does not grow. 
In all other cases we suppose the fetus living, but as far as treat- 
ment is concerned, treat all cases as if fetus were alive ; if dead, it 
will soon be expelled ; if alive, pregnancy may continue to term. 

Prognosis — For the child, bad, because the fetal death often 
the cause of the abortion ; the fetus is born at a time when it is not 
viable. Of course, the nearer the seventh mionth the better the prog- 
nosis. 

For the mother : Prognosis as to life is good, very few die. 
From hemorrhage seldom, because even if she loses much blood, 
faints, clotting. Still, women do die from hemorrhage, especially 
if after long continued, frequent hemorrhage another severe hemor- 
rhage. Usually death is from sepsis. Amount of blood which is 
dangerous to woman varies. When an abortion with sepsis, sus- 
pect criminal operation. Symptoms of sepsis with abortion are: 
temperature, pulse, pain, discharge fetid, etc. Of the deaths, ma- 
jority due to sepsis, peritonitis, pyemia. Prognosis as to health, bad. 
Abortion worse for woman than labor at full term. Involution is 
slower, lasting two to three months, and if sepsis, almost always 
some subinvolution. Endometritis often remains behind, due to 
retention of some part of the decidua, when we find decidual cells, 
like at labor, for a long time after. Endometritis post abortum or a 
hypertrophied condition of the endometrium ; endometritis intersti- 
tialis ; rarely endometritis glandularis. Very often some pelvic cellu- 
litis. Not seldom women invalids for life. 

Treatment — Treatment of habitual abortion or recurrent abor- 
tion. Find the cause and treat the cause,- — Syphilis, chronic endo- 
metritis, retroflexion. Examine the woman. During pregnancy, 
ki, kclo3, A^iburnum, all useless ; rest in bed, — not all the time, 
but only during menstrual periods ; former cruel and useless. Later, 
when premature labor threatens, may be tried. If chronic endo- 
metritis, keep all accidents away. Alterative tonics in pregnancy. 

Treatment of threatened abortion: Only object is to arrest uter- 
ine contractions, — rest in bed, opium, gr. ^4 morphine every four 
hours. More if necessary, and can be watched. Light diet, tincture 
opium, 20 min., per rectum, repeat every two hours. Hemorrhage 
cases, keep in bed two to four days after all flowing ceased, and 
should very gradually resume active duties. Go to bed again when 
the first show appears. If, after a time, examination should show the 
presence of a dead ovum, let the abortion take place. Abortion is 
inevitable when there is a history of clots of various sizes being 
passed ; inevitable when hemorrhage is profuse ; when uterine con- 



NOTES ON OBSTETRICS—SENIOR CLASS. 317 

tractions continue in spite of treatment. These cases almost always 
terminate in complete evacuation of the uterus. But sometimes, 
even if the ovum has reached the cervix and the hemorrhage has 
been very profuse, the pains and hemorrhage may cease, the cervix 
close and the pregnancy go to term. 

Abortion in Progress — Opinions differ widely as to its treatment. 
vSince there are so many abortions, and if sepsis does not complicate 
them they get well so uniformly, w^e can adduce various reasons 
for this diiTerence of opinion : '^ > 

1. A large number get well alone. 

2. Different abortions require varied methods of treatment, i. e., 
cannot fit all to one form. 

3. Some abortions recover under any form of treatment, i. e.^ 
there are several good methods of treatment for a given abortion. 

The treatment of abortion is watchful expectancy. Same as labor 
at term. While the treatment is expectancy, expediency may de- 
mand an active part of you, e. g., you live a long way off from the 
patient and cannot stay at bedside. The indications for interfer- 
ence, aside from expediency, are: i. Hemorrhage. 2. Sepsis. If 
hemorrhage is profuse, interfere. If the cervix is not yet dilated, 
tampon the vagina. If the cervix is effaced and admits one finger 
easily, or two, remove the ovum, — pressure, traction, ether and 
manual removal. 

Vaginal Tampoih — Is not devoid of danger, because of sepsis, 
already present in the vagina, or introduced with the tampon ; fur- 
ther, the tampon is painful, and usually causes retention of urine, — 
better of two evils, however. 

Technique — Sim's speculum, long forceps, douche point, catheter. 
Patient across bed, or Sim's position, or knee-chest position ; scrub 
with soap and water, clip long hair, hands clean, vaginal douche, 
scrub parts, cervix cleaned (douche in dorsal position). Have every- 
thing at hand. Cotton wrung out of ^% lysol, or plain sterilized 
cotton, and a small piece weak iodoform gauze. Have enough pled- 
gets. Catheterize. Speculum held by husband or sister or nurse. 
Pack cervix tightly with the iodoform gauze. Two fingers guide the 
cotton and pack it around cervix, then against cervix till upper half 
of vagina full and tight, then lower half not so tight. Big pledget 
against vutva, T-binder, bed. Take the temperature every four 
hours, and a rise above 99.6 indicates immediate removal of the tam- 
pon. Leave the tampon from 6 to 24 hours, according to circum- 
stances, never more than 24 hours, average 12 hours. Remove and 
often find ovum on tampon or in the cervix. If the cervix not di- 
lated, tampon again. If the ovum is not expelled now^, it is because 
it is pathologically adherent and must be removed by hand. Tam- 
pon first excites uterine contractions ; second, blood accumulates on 



318 NOTES ON OBSTETRICS—SENIOR CLASS. 

top of the tampon and separates ovum from wall of the uterus. If 
the cervix is dilated we may tampon or remove the ovum. Great 
difference of opinion. 

As was said, treatment is watchful expectancy, but if hemor- 
rhage is great, must do something. If ovum is in cervix, pressure 
may remove it complete, — two fingers in the anterior fornix, hand 
over fundus ; or traction on the extruded part, two vaginal fingers 
exert gentle traction. Take time and may succeed. If unsuccess- 
ful, and there is indication to empty the uterus, operation is neces- 
sary. 

Instruments — Uterine catheter, Bozeman, — zinc or a large silver 
male catheter, glass good but fragile, specula, uterine packing for- 
ceps, and tubular packer. Curettes, sharp, large. Tenaculum for- 
ceps, 8-inch forceps, chloroform or ether, assistant. Dorsal position, 
scrub, clip hair, vaginal douche i% lysol ; in septic cases, uterus 
also. Hands very carefully prepared, half hand in vagina, one or 
two fingers in the cervix, into uterus, hand outside forces uterus over 
finger like a glove and the finger softly separates the adherent por- 
tion of the Qgg. After all is separated, use expression as described. 
Sometimes very adherent at placental site, hence care to keep whole 
and separate gradually. After the ovum is removed give a ''re- 
vision" of the uterus and separate with the finger nail all retained 
portions. Uterus should be smooth except at the placental site 
which is a little elevated from the surface and rough. Sometimes, 
especially in the early weeks, decidua too adherent, or the finger too 
cramped to work well. Here use the curette, locate piece with the 
finger and go in and scrape it off. Care because of danger of per- 
forating the uterus, therefore, gently and note how far the cur^ette 
goes in. Curette the whole surface till it is smooth. Now pro- 
longed irrigation of the uterus with i% lysol or light tincture of 
iodine. Optional whether you put iodoform gauze in uterus. If 
there is hemorrhage or sepsis, the uterus may be packed, in the 
former tightly, in the latter, loosely, and with weak iodoform gauze. 
To be removed in four to five hours. 

Incomplete Abortion — Means those cases w^here fetus escaped 
and all or part of the secundines are retained in utero. 

Diagnosis — Not always easy. i. History, which may fail. 2. 
Signs of pregnancy. 3. Local examination, (a) soft vaginal walls ; 
(b) softened patulous cervix; may be shreds of membrane; (c) 
large, flabby uterus; (d) hemorrhage, and if sepsis, pain, fever, fetor 
to discharge ; color, dark brown. Remember ectopic pregnancy. 

Treatment — There are two views: i. Clean out the uterus at 
once. 2. Tampon uterus and vagina and wait. 3. Wait and op- 
erate only under some indication, — hemorrhage, sepsis. I prefer the 
more active course, but let circumstances govern the method of 



NOTES ON OBSTETRICS—SENIOR CLASS. 319 

procedure. If the hemorrhage is profuse or repeated often there is 
no other course but to clean out the uterus. If the patient has fever, 
same treatment; if neither present, justifiable to wait. If you live 
iar away, clean out the uterus. Clean out the uterus is the rule, wait 
the exception. It is easy to do this when os is dilated or dilatable. 
Usually easy in multiparae, harder in primiparae. Dilatation of the 
cervix often an important point. Various methods : 

I. Sponge tents, not good, septic. 2. Laminaria, hard to steril- 
ize, slow and not very efficient. 3. Steel divulsors, rapid but dan- 
gerous, because of laceration. 4. Best are Hegar's dilators. Can 
sometimes dilate cervix in 15 minutes. Dangerous, too. 5. The 
finger, very good dilator. 

Procedure is exactly same as described. Fingers to be used 
in all possible cases and, as experience grows, used almost exclusive- 
ly. Remember the danger of perforation of uterus. After all abor- 
tions give ergot and hydrastis for a week or more, to favor involu- 
tion. 

Treatment of Septic Abortions — Empty the uterus thoroughly as 
quickly as possible. If the cervix is dilated remove with the 
fingers, and be sure to leave the endometrium smooth. Give a pro- 
longed uterine, 1% lysol, douche before and after removal. Put 
a piece of iodoform gauze in uterus and remove it after 4 to 5 hours. 
The treatment is the same whether the whole ovum is in the uterus 
or only a part. Clean out the uterus. May be hard to deliver the 
fetus. Try expression, after detaching the ovum. Pull the ovum 
out by hooking the finger over it. If the fetus is larger, say the 4th 
or 5th month, turn it and extract by foot, but beware of pulling the 
body from the head. Aid with a long polypus forceps, or a stone 
forceps. After this, scrape out the placenta, etc. It may be neces- 
sary to dilate the cervix with the finger or Hegar's dilators. If there 
are symptoms of peritonitis it is a bad case, and extirpation of the 
uterus may be more surgical a procedure. Hard to decide. Chill 
and high fever likely to follow intervention. 

To Sum Up the Treatment of Abortion — 

(i) Watchful expectancy as long as the hemorrhage is not 
great and there is no sepsis. 

(2) If hemorrhage is great and cervix not dilated, no tempera- 
ture, tampon vagina. 

(3) If hemorrhage is great and os dilated, remove ovum, ex- 
pression, traction, manual removal. 

(4) If abortion incomplete, remove everything in the uterus, 
dilating cervix if necessary. 

(5) In septic abortions, clean out the uterus antiseptically with 
fingers, and put in a strip of iodoform gauze for iom or five hours. 

Schaefifer, of Heidelberg, found that the women that had been 



320 NOTES ON OBSTETRICS—SENIOR CLASS. 

curetted after abortion had better health than those who were not ; 
that there is less of menstrual irregularities, less subsequent abor- 
tions and more full term labors and less trouble with the labors^ 
especially with the third stage. Usually the abortion was preceded 
by some trouble with the endometrium, or the general system, and 
this is aggravated. 

Changes in the Ovum After Death of Fetus — If the fetus dies. 
in the early weeks the chorion and the decidua which are nourished 
by maternal blood may go on growing. But hemorrhages, apo- 
plexies, are very common in the decidua and one causes another till 
the whole periphery of the ovum is invaded. The cavity of the 
amnion is crowded together, or the blood may in rare cases break 
into the ovum itself. Or the membranes may undergo an eccentric 
hypertrophy and the cavity grows larger, fills with amniotic fluids 
and may be of the size of an ovum of two months. Adhering to 
one side you find a fetus of three weeks. This is called a "blood 
mole." When they are older and, to a certain extent, decolorized, 
they are called ''fleshy moles." History of such cases is : they 
usually cause repeated greater or smaller hemorrhages till finally 
the uterus expels themi, or the attendant interferes. 

Later in pregnancy, when the fetus already has some size, varied 
changes may occur before the ovum is expelled : 

1. Most common is Maceration. Fetus imbibes blood and is 
stained. Tissues soft. Bones loose, especially cranial. Skin larger 
than the body, epidermis falls oflf in big pieces ; red corium exposed. 
Cord thick and stained with blood. Placenta, which may go on 
growing, is larger than the size of the fetus would demand, and is 
pale and soft. Impossible to tell how long a fetus has been dead 
by the changes, because sometimes little changed after many days, 
and again, changed much in a few days. Due in part to presence 
of digestive ferments in liq. amnii. 

Runge said the vitreous humor became cloudy on the third day, 
then the lens from without inward. Called Fetus Sanguinoletus. 

2. Mummification — Fetus dries up. Very little liquor amnii. 
Fetus dry, gray, sometimes leathery. Organs dry, sometimes 
cheesy. Bones and tendons least affected. Occurs oftenest with 
twins, when one is found pressed against the uterine wall. Fetus 
Compressus, or thinned out like paper, fetiis papyraceous. Cause is 
-—one fetus dies some time during pregnancy, the other goes to 
term, while the dead one dries up. Also occurs when the fetus dies 
from the cord being around the neck, etc. 

3. Lithopaedeon — A Lithopaedeon may form. Process is the 
same as in extra uterine pregnancy. Not so frequent as in cows 
and sheep. 

4. Septic Infection — Septic infection of the uterine contents oc- 



NOTES ON OBSTETRICS—SENIOR CLASS. :i2 1 

curs, but this is usually due to futile attempts to enipty the uterus. 
May occur of itself. 

THE PATHOLOGY OF LABOR. 

An obstetric case is a surgical case, with more than usual as- 
pects. Best to regard every labor case as a severe operation, and, 
like the surgeon, the obstetrician considers first the strength of the 
patient to stand the shock ; second, the asepsis and antisepsis ; third, 
the nature and technique of the operation ; and fourth, the complica- 
tions likely to arise. 

So, during labor, it is necessary and our duty to have a clear 
knowledg-e of the patient's conditions, especially heart, lungs, kid- 
neys and blood; second, we must know accurately what is going on 
during the labor, i. e., a knowledge of the mechanism of the particu- 
lar labor, of the strength of the povv^ers, of the greatness of the re- 
sistances and the relation between them ; third, we must be aware 
of all possible complications and the particular ones likely to arise 
in this particular case, and know how to prevent and treat them ; and, 
finally, we must know and practice the strict principles of asepsis 
and antisepsis, that the latest standards demand. To meet all these 
obligations is the duty of the obstetrician, and a conscientious man 
will find little time for idling at a labor case. It requires studious 
regard of the patient during her pregnancy, and getting her into the 
best possible condition for labor. It requires a prompt response to 
the call to the labor, a careful and painstaking examination on ar- 
rival, and a proper valuation of all the conditions found. It re- 
quires attentive conduct of the case from beginning to end, and a 
preparedness for doing the usual work of a confinement case, plus 
far-reaching provision for all emergencies. 

In general, we find the abnormalities of a labor under three 
heads : 

(i) Anomalies of the powers. (2) Disproportion in the pow- 
ers, and the resistances due to too small passages. (3) Complica- 
tions, either maternal or fetal. 

In the study of these three aspects of a case we often find rea- 
sons for interference with the course of nature. We call this an- 
"indication" to interfere. There may be, however, certain require- 
ments in the case which may cause us to modify the indication. We 
call this a ''condition." A condition governs the indication, e. g., 
a woman in labor develops eclampsia. The indication is to deliver at 
once, but the cervix is closed. The state of the woman demand- 
ing delivery is the indication ; the state of the cervix, which- governs 
the indication, is the condition. 

When a condition prohibits the course of procedure called for 



"■^'21 Notes on oBstetrics—seMior class. 

by the indication, it is called a contra-indication. The determina- 
tion that a given case requires this or that remedy, or course of 
conduct, we call "placing the indication," and only when the indi^ 
cation is clear and all the conditions fully met, may we act. 

The Powers of Labor — Are, ist, the uterine contractions; 2nd, 
the abdominal muscles ; 3rd, the contractions of the vagina ; 4th, 
gravity. Of these, the uterine contractions and the abdominal mus- 
cles alone are important, and we may have anomalies of either of 
these. 

In the Urst stage of labor the uterus does all the work. Regular- 
ly, every five to ten minutes, its muscle contracts, slowly reaching 
acme, then relaxing. In this way the lower uterine segment is 
formed, the cervix effaced, the bag of waters formed, the os dilated. 
As a result of the extension of the fetal body and the general 
intrauterine pressure, the fetus advances through the birth-canal. 

In the second stage, the larger part of the work is done by the 
abdominal muscles, — abdominal pressure. This is proved by the 
following points: ist. That the weakly developed woman may not 
be in position to expel the child. 2nd. Women have refused to exert 
the abdominal muscles, and the labor stood still. 3rd. The uterus 
has by this time drawn well up over the child, and can exert but 
little power. Still, in some cases the uterine powder does expel the 
child, and in all cases it serves the purpose of forcing the child 
against the perineum, which causes the action of the abdominal 
miuscles reflexly. 

We have, in reality, two forms of w^eakness of the powers ; one, 
of the uterine power, another of the ahdoininal pressure. The ab- 
dominal pressure is subject to important anomalies, which are not 
generally recognized, most attention being directed to the irregular- 
ities of the uterine action. 

The abdominal pressure may be too strong, in that the patient 
bears down so much as to endanger the soft parts by too rapid exit 
of the head. If the bearing dowm efforts are strong before the cir- 
vix is dilated, this may be tern and post partum hemorrhage caused. 
If the patient bears down too much when the head is passing the 
vulva, the vagina and the perineum may be torn more than is neces- 
sary. The baby, too, may be injured by too rapid delivery, e. g., 
intracranial hemorrhage, or by being hurled against the foot of the 
bed or to the floor. Women have fractured the sternum in a few 
instances. 

Weakness of the abdominal muscks is more common. It occurs 
in inflammatory conditions in and about the pelvis, e. g., peritonitis ; 
in cardiac and pulmonary diseases ; hernia, umbilical, inguinal or 
femoral hernia ; in some spinal cord affections ; during narcosis or 
coma ; and sometimes in weak women or those who are exhausted 



NOTES ON OBSTETRICS—SENIOR CLASS. 323 

by long- labor, or who have started to make bearing down efforts too 
early, in the first stage of labor. 

The treatment of too strong abdominal effort is lateral position, 
warning to the mother, narcotics. The treatment of the weakness 
of the abdominal pressure varies with the cause. In cases of in- 
flammatory conditions in the abdomen and in cardiac and respiratory 
affections, the patient should not bear down. Labor must be termin- 
ated by forceps. If the patient is tired out, morphine or chloroform 
may give her a short respite, after vvhich she may work to better 
advantage. A change in position from the side to the back, or back 
to the side, may be useful. If the second stage is well advanced, the 
patient may be given the arm of the husband, or the physician, to 
pull on, and instructed how best to use her remaining power. She 
may be allowed to sit up. The use of the obstetric chair is recom- 
mended by Ahlfeld. Ritgen's maneuver has been done, pressing out 
the head with two fingers operating from the rectum. This, in my 
opinion, is somewhat risky, — danger of injury to rectum. Kris- 
teller's expression may be used in selected cases. This consists of 
pressure by means of the two hands spread evenly over the fundus, 
downward in the direction of the axis of the inlet. Even pressure, 
during a pain, slowly increasing, slowly decreasing, not too much 
force, never when the lower uterine segment is thinned, seldom in 
multiparae, — are the rules for success. It is not without danger, — 
rupture of the uterus, dislocation of the placenta, injury to the ab- 
dominal viscera. Hofmeier recommends pressing the head into the 
pelvis with the hands. If all that is needed is to overcome the re- 
sistance of the perineum, an episiotomy may be done. Should those 
measures fail, the forceps may be used, and 75% of forceps op=- 
erations in America are done for conditions of this kind. 

Anomalies of Uterine Action — These are not common, but there 
are many varieties of pains. These vary in different women, in dif- 
ferent labors, and in the different stages of a labor. Too little study 
has been given the varieties of labor pains and their clinical sig- 
nificance. 

The pains may be too infrequent, i. e., the long intervals com- 
mon to early in the first stage, may be found in the second stage. 

Dangers here are sepsis and prolonged impaction of head in 
pelvis. The infrequent pains, too, do not stimulate the abdominal 
muscles. Labor in such cases may drag on for days. Patient will 
have pains at long intervals, or have a series at short periods, then 
a rest of several hours, or may be days. If the condition persists, 
the temperature rises, and then the pains usually come on, quickly 
terminating the labor. . 

The weak pain or inertia uteri is due to many conditions. It 



324 NOTES ON OBSTETRICS—SENIOR CLASS. 

may be actually weak, or relatively so, in regard to the resistance to 
be overcome. 

The actually weak uterine contraction may be due to poor general 
health, tuberculosis, chronic wasting disease, anemia, or acute dis- 
eases, but the pains are often strong in these conditions. 

There are local causes for inertia uteri, as too great distension ^ 
of the uterus, by hydramnion, by twins, or inflammation, by physo- 
metra, abnormal position of the uterus (anteversion), tumors. The 
uterus may be weakened by hemorrhage ; it may be anemic from un- 
equal pressure on the fetus in dry labors. 

The uterus may be tired from long effort; either the muscle was 
poorly developed, e. g., infantile uterus, weak women or the labor 
is lasting too long; the uterus may contract irregularly, forming 
contraction rings at various points ; finally, the uterus may be de- 
formed, uterus bicornus, or septus. 

The nervous mechanism of the uterus may be disturbed, a shock 
will often drive the pains away, or fear of an operation hasten 
them. The suffering they cause may be sufficient, in hyperesthetic 
women, to inhibit them, and it may seem paradoxical, but morphine 
may strengthen weak pains. 

Diagnosis — The diagnosis is easy. The uterus does not harden 
during a pain, the patient complains of little suffering, there is no 
progress in the labor, and no effect on the fetal heart tones. The 
relaxed condition of a uterus near the point of rupturing is easy 
to separate from the condition being described. 

Atony of the uterus sometimes occurs in the third stage, leading 
to hemorrhage, retention of membrane, and pieces of placenta. A 
paralysis of the placental site exists, the remainder of the uterus 
contracting well. 

Treatment — The treatment of weak pains varies with the cause. 
A_ rest obtained by chloral, gr. xv to xxx, is one of the best 
means. Morphine, gr. y^, good — with the chloral, perhaps. Stimu- 
lating drugs usually not recommended. No quinine or ergot. 
Strychnine, coffee and a little wine of most service when stimulating 
drugs are needed. 

Locally, a small colpeuryter may be placed in the cervix and 
drawn upon, or in the vagina. A bougie in the uterus will stimu- 
late pains. 

Suggestion to be employed, with moral and mental support. Hot 
bath, especially the hot sitz bath, and abdominal massage. Electric- 
ity may be tried ; use the faradic current, but not strong enough to 
cause pain. 

Watchful expectancy to be used, but see that the patient does not 
suffer too long, because of sepsis and the depressing effect on the 
nervous system of long labor. Keep up nourishment. 



NOTES ON OBSTETRICS—SENIOR CLASS. 325 

The pains may be too frequent, and at the same time too strong, 
but they are usually irregular in strength, and do not produce com- 
mensurate progress in the labor. They are produced by too fre- 
quent and rough examinations, restlessness of the patient and inordi- 
nate use of the abdominal muscles. The frequency of the pains is 
dangerous to the fetus by preventing the change of the blood in the 
uterus (asphyxia), and bad for the mother, because the uterus needs 
a rest between pains and the general system, too. Nervous mani- 
festations may arise. If the pains are too strong and too frequent, 
there is danger of laceration of the cervix, and the perineum, by the 
rapid exit of the child ; the latter may be hurled into the world and 
suffer injury, e. g., fracture of skull, the cord sometimes tears from 
the body, or the placenta, but hemorrhage not usual. Post partum 
hemorrhage may occur, even inversio uteri. Sometimes syncope. 

These are called precipitate labors, and may sometimes occur 
when the patient is on the water closet, w^hen the infant may be 
lost. Important from a medico-legal standpoint. 

The pains may last too long, over 60 or 90 seconds. Causes 
same as too strong pains and irritation of the lower uterine segment 
from maladaptation of the presenting part on the pelvis, e. g., flat 
pelvis, shoulder presentation, after rupture of the bag of waters. 
The use of ergot during labor and attempts to hasten things by va- 
rious manipulations. 

Tetanus Uteri — ^If combined with severe suffering, they are 
"cramp pains." Labor does not progress, rather is retarded ; the 
fetus is endangered by asphyxia, sepsis is invited, the patient is soon 
in a highly excited condition, which may approach acute mania, and 
if not relieved may die of exhaustion. 

The pains may be too painful, i. e., the suffering may be incom- 
mensurate with the strength of the uterine contraction, and with 
the progress in labor. This is found in small, nervous, fearful, 
hyperesthetic women. Often hysterical, and may be simulated. Re- 
quires discrimination to diagnose these different conditions. 

Treatment — The treatment is on general lines. Narcotics, of 
which chloral and opium best, by mouth and rectum, in large doses, 
e. g., 30 gr. chloral per rectum, and gr. ^ by mouth ; repeat in two 
hours if necessary to procure rest. Give prolonged warm full bath. 
No manipulations on uterus or per vagina. Chloroform may be 
given to the obstetrical degree, but sometimes it is better to put the 
patient to sleep for three-quarters of an hour and when she wakes 
the pains are more regular. 

The uterus may contract irregularly in places ; when the contrac- 
tion ring of Bandl is ' contracted, a condition spoken of as "hour 
glass" results. This may imprison the fetus by grasping its body 
and impose an obstruction to the passage of the trunk. If forceps 



326 NOTES ON OBSTETRICS—SENIOR CLASS. 

are applied, the uterus may be injured. If in the third stage, the 
constriction occurs, it may lock the placenta in, and give rise to 
severe hemorrhage. Caused by brusque manipulations on the uterus 
and use of ergot, and meddlesome attempts to hasten delivery. Ir- 
regular contractions are observed during pregnancy. 

Treatment — The same as the last condition. 

Anomalies in the Passage and Passengers — The second factor 
m a given labor is the Resistances, i. e., the relation of the force 
exerted by the powers on the fetus against the passages. The stud\ 
of these things so as to properly estimate the amount of resistance 
offered by the fetus to the passages, oi by the passages to the fetus, 
the one or the other being abnormal, is an important part of the 
conduct of every labor. 

Abnormal Resistance by the Passages — Obstructions of the soft 
parts : 

(i) Rigidity of the cervix. Of this there are two kinds: (i) 
Anatomical; (2) Spasmodic. The first is a pathologically changed 
cervix, the second is due to spasm of the muscle fibres. Causes of 
the first are: (a) chronic cervical endometritis; (b) scars from 
cautery or Emmett's operation; (c) syphilis; (d) old ulcerative 
processes; (e) conglutinatio Orificii externi ; (f) old primiparae, have 
often lack of dilatability ; (g) carcinoma. 

The second form is due to rough and frequenc examinations, 
frequent and strong uterine pains, ergot, highly excited patient, pro- 
longed labor. 

In the first class, there is an anatomical basis of the rigidity. 
A great deal depends on the site, if in the supra-median, or vaginal 
portion of the cervix. Wherever located the cervix dilates under the 
influence of the pains up to the obstruction. If the pains are strong 
enough after a certain period the part dilates. If part does not dilate 
the child dies and the uterus may rupture, or the cervix may tear 
across and the child be born through the rent, or the cervix may tear 
off circularly. Cases of pathological stenosis of the cervix are rare. 
Slight induration which makes labor longer, but allows a spontane- 
ous termination, are not rare. 

Conglutinatio Orificii Externi is a condition where the few cir- 
cular fibres around the external os refuse to dilate ; as a result the 
cervix is not dilated, but thinned by the head and may be delivered 
externally still covering the head. The os cannot be found by the 
finger, but the opening can be seen in the speculum as a tiny hole 
with a little mucus and surrounded by a very red ring. The finger 
can overcome the resistance of the external os and then the dilation 
goes on rapidly. 

Treatment of pathological stenosis of the cervix : When, after 
strong pains have made no impression on the cervix, and something 



NOTES ON OBSTETRICS—SENIOR CLASS. 32V 

must be done, there are three methods of enlarging the cervix : ( i ) 
the hand; (2) rubber bags ; (3) incisions, Hysterostomotomy ; (4) 
Bossi's dilator; (5) vaginal Cesarean section. The hand succeeds in 
the mildest cases, as do the rubber bags. Tarnier has invented an 
instrument shaped like a three- leaved speculum with the ends turned 
off at right angle. This is not often successful and is very painful ; 
it is likely to slip off, or tear and bruise the cervix. Incisions in 
the cervix are made to either side. An angular scissors with blunt 
points is used, or a blunt-ended bistuory. The cervix must be pro- 
tected by two fingers, the incisions may be one inch deep. In the 
subsequent extraction they usually do not tear further. In certain 
cases it may be necessary to cut the cervix laterally to the fornices. 
This, together with the rapid extraction of the fetus, is called Ac- 
couchment force, or forced labor, and is sometimes done in cases of 
eclampsia. Formerly done in placenta previa, but not to be recom- 
mended. 

Bossi's dilator dangerous and not more efficient than the hand. 
Vaginal Caesarean section useful in operations from sixth to eighth 
month of pregnancy. At term quite serious operation. 

Spasm.odic rigidity of the cervix may be diagnosed in the cases 
given by recognizing the cause. In these cases also the parts are 
hot and dry. In the speculum they are red. 

Treatment — Leave the patient as much as possible alone. Give 
a hot bath or a sitz bath prolonged for 20 minutes. Put an ice cap 
on the head or a cold wet cloth around the neck to prevent congestion 
of the head ; chloral and morphine. The best remedy is chloroform 
to the obstetric degree. In these cases it hastens labor, or the patient 
presses harder now that the pain in the cervix is gone ; the muscles 
of the pelvic floor are said to relax also. 

Stenosis of the vagina may occasionally give rise to dystocia. 
The stenosis results from old ulcerative processes, e. g., from puer- 
peral fever, from previous confinements, e. g., hard forceps and 
scarring, or from gonorrheal vaginitis. There may be a congenital 
narrowness of the vagina, or there may be a septum which extends 
more or less far in the vagina (the relic of fetal development). Fin- 
ally, the vagina may be relatively small. That is it may be normal, 
but there is some indication for the rapid termination of labor anH 
the vagina is unprepared for it, e. g., cases of eclampsia and placenta 
previa. 

Treatment of cases of pathological stenosis is, — when they offer 
such resistance to labor that interference becomes necessary, to cut 
the bridges of scar tissue. If not possible or if too much tissue to 
sever, Caesarean section and subsequent amputation of the uterus, 
if the opening in the vagina is not large enough for the lochial flow. 

Obstruction may be met at the vulvar outlet, Cases of concep- 



828 NOTES ON OBSTETRICS—SENIOR CLASS. 

tion through a pin-hole hymen. At labor the hymen is distended 
over the head. From the pin-hole opening- the bag of waters some- 
times protrudes. Child may die, or case become serious from 
threatened rupture of the uterus. 

Treatment — Incise the hymen laterally. The vulva may be 
■scarred from ulceration. Treatment — Incision. 

Sometimes meet a transverse ridge in the vulva analogous to the 
septum, sometimes in the vagina. Section of the band. 

Tight Perineitm — Cases where it is altered by old ulceration, or 
infiltration, or perhaps from bicycle riding, where it has been torn 
and sutured too high, in old primiparae and sometimes without any 
definable cause, the perineum is hard, not dilatable and may offer a 
hindrance to labor. This may also come from a tight vulvar outlet. 
Vaginismus — The skin is easily stretched, but just under this inside 
the vulva, can feel a tough ring. When the perineum offers an evi- 
dent obstruction to labor the proper treatment is episiotomy. Usu- 
ally an incision on one side is enough. Many a forceps operation 
may be saved by this simple operation, only the conditions must be 
recognized. Chloroform will relax a perineum that is spasmodically 
contracted. 

The ring of Bandl sometimes is spasmodically contracted, and 
locks the body of the child in place. Hard to diagnose. 

Treatment — Narcotics. 

The membranes are sometimes a source of obstruction to labor 
and a slightly increased resistance here may be the cause of great 
delay. They may be either adherent over the internal os and lower 
uterine segment, thus preventing the dilatation of the same, or they 
may be so tough that they do not rupture when the cervix is dilated. 
In either case labor is delayed, in the one at the beginning, in the 
other at the end of the first stage. The second is easily recognized 
— delay after complete dilatation. 

Treatment — Rupture the membranes after delay manifest for 1^2 
to 2 hours. Fix head from without over the inlet if not engaged, 
to prevent prolapse of the cord and extremities and be sure that 
there is no contracted pelvis or malposition of the presenting part. 
The recognition of the first is more difficult. By examination one 
may feel the adherences and it is justifiable to separate them with 
the finger, gently and having assurance that the placenta is not near- 
by, which is not rare. If one does this and pushes up the head a 
little so as to allow a little liquor amnii to flow into the loosened 
membrane, thus forming a bag of waters, that will dilate the cervix, 
much may be accomplished. 

In some rare instances it may be necessary to rupture the mem- 
branes even early in labor, but these conditions must be fulfilled : 
I. The head must be engaged. 



NOTES ON OBSTETRICS—SENIOR CLASS. 829 

2. Pelvis not too contracted, outlet at least 8 cm. 

3. Rotation complete or nearly so. 

4. No anatomical rigidity of the cervix or vagina. 

5. Presentation must be normal. 

The parturient canal may be blocked at any point by tumors, ex- 
travasations, displacements of the cervix, vagina, by the full bladder, 
or rectum, etc., iDut the course is not long enough for their consider- 
ation. 

OBSTRUCTIONS OF THE BONY PELVIS. 

In 1572, J. C. Arantius, a pupil of Vesalius, discovered the con- 
tracted pelvis. In 170 1, Deventer published a description of flat 
and generally contracted pelves, and is really the founder of the 
study. Michaelis, who died in 1848, did the most for the study of 
contracted pelves and his work is classic now. Very recently Breus 
and Kolisko have published parts of a great work on the subject, 
which is more from the pathologist's than from the clinician's 
standpoint. 

Contracted pelvis is more frequent than is generally thought. 
It was considered rare in the United States until accurate measure- 
ments showed otherwise. High degrees of contraction are com- 
moner abroad because ' of the poorer population and the poorer 
foods, etc. 

In Germany 14% of cases and in the United States about 8% have 
small pelves. 

Contracted pelves are of all degrees, first, the absolutely con- 
tracted, below 6y2 cm., where a living child can under no circum- 
stances pass ; second, relatively contracted, from 6^ to 9 ; and the 
third class, from 9 to the normal. 

The pelvis is by no means all important in labor. The size of 
the child and its position are of great significance. A large child 
may make a normal pelvis too small, and a relatively small one, 
absolutely contracted, and a small child may slip through a quite 
contracted passage. It is the relation, therefore, between the size 
of the child and of the pelvis that we must study. In the succeed- 
ing pages we will consider the child to be the average size. 

The importance of contraction of the pelvis lies usually not so 
much in the actual diminution of the size of the passage to be tra- 
versed by the child as in the anomalies of position, of presentation 
and of attitude, of the fetus, and of alterations in the character of 
the pains, and the relations of the soft structures. The subject is 
thus very complicated. 

The narrowing of the pelvis may occur in any plane, or in all of 
them, it may occupy one side, it may be typical and again all sorts 
of asymmetrical forms occur. Most often the inlet is contracted, but 



330 NOTES ON OBSTETRICS—SENIOR CLASS. 

the outlet is also found too small ; of all the diameters the C. V. is 
the one commonly found to be at fault. 

It is impossible here to describe all the varieties of deformed 
pelves. We will take up the most common. For clinical purposes 
we distinguish four kinds of pelves. 

1. Those contracted in the anterior posterior diameter — flat. 

2. Those contracted in all diameters — generally contracted. 

3. Those flat and generally contracted. 

4. Those asymmetrical pelves, a large group of rare forms. 
The flat pelvis is usually rachitic, but there are cases without any 

signs of the disease. 

Factors in Formation of Deformities — The factors in the forma- 
tion of the adult heart-shaped pelvis from the anterior-posterior 
ellipse of the infant are first, the inherent tendencies of growth, and 
second, the mechanical factors. The latter are better understood. 
They are three in number. The trunk pressure, the lateral pelvic 
tension, the lateral pelvic pressure. The weight of the trunk on the 
sacrum has a tendency to force this bone out from the ossa in- 
nominata. There is no wedge action to the sacrum. The trunk 
or body pressure likewise tends to throw the top of the sacrum 
down and forward, further it presses on the bodies of the sacrum 
and if these are not healthy interferes with their growth. The 
effects of trunk pressure are, first, by pushing the sacrum down and 
forward, it pulls on the sacro-iliac ligaments, tending to bring their 
insertions together ; this tends to pull the ilia apart at their anterior 
junction, the pubis, which failing, owing to the rigid joint, the 
anterior wall of the pelvis nears the sacrum. This is the lateral 
tension. It resembles the stretching of a ring between two points — 
the -ring becomes an ellipse. The body, supported on the femora, 
presses downward on them; they press upward (law of physics) ; 
since the heads are set at an angle, part of this upward pressure is 
deflected laterally into the pelvis. This is the lateral pressure, and 
it operates against the lateral tension. By a proper balancing of the 
three and proper tendencies of growth, the normal pelvis results. If 
one or the other factor is lacking or is exaggerated, one or the other 
deformity results. 

The flat pelvis is the effect of too great trunk pressure acting on 
the softened bone, or too little lateral pressure. 

The child with rachitis walks late, or sits in bed for months. 
The trunk pressure produces great lateral tension which is not off- 
set by the lateral pressure. As a result the sacrum tips into the pel- 
vis ; the lower end, being held by the great sacro-sciatic ligaments, 
the sacrum becomes sharply curved and the ischiatic tuberosities 
strongly developed. The pressure also pushes the bodies of the ver- 
tebrae forward from the wings, and the lateral concavity of the bone 



NOTES ON OBSTETRICS—SENIOR CEASS. 351 

is destroyed. The pubis approaches the promontory and the heart 
shape of the inlet is changed to a transverse elUpse. The outlet is 
often enlarged. 

The flat non-rachitic pelvis presents a mild degree of contrac- 
tion without other signs of softening of the bones. 

Labor in flat pelves is characteristic. One can usually diagnose 
the kind of pelvis from the character of the labor. Abnormal pre- 
sentations are four times as frequent in flat as in normal pelves, and 
because the head cannot enter the pelvis it slides off to the side, 
which allows prolapse of the cord, of the extremities and later shoul- 
der presentation. Owing to the fact that the head is retarded un- 
equally, the various deflexion attitudes result, forehead, brow and 
face presentation. 

To aid in this disturbance, pendulous abdomen is common, and 
this causes anomalies in the mechanics of labor. The combination 
causes anterior and posterior parietal bone presentations, which are 
more dangerous than the mechanical disproportion. In breech pre- 
sentation the feet prolapse. 

In primiparae these abnormalities are less common than in multi- 
parae, who also lack the powerful, young, well nourished muscular 
uterus. Contracted pelves, therefore, grow more serious with re- 
peated labors. Labor is longer than normal, the bag of waters often 
ruptures early, which delays the dilatation of the cervix, because 
there is nothing to stretch it. Later the caput succedaneum may 
dilate it. After the cervix is open the head rolls into the pelvis, 
first the posterior parietal, then the anterior rolls in from behind 
the pubis. This may be seen by the impressions which the promon- 
tory makes on the scalp and skull. 

The pains and the conduct of the uterus are highly important in 
these labors. Usually in flat pelves the pains are strong, some- 
time tumultuous, and endanger the integrity of the uterus (dan- 
ger of rupture). These pains mould the head into the pelvis so that 
sometimes great disproportion is successfully overcome. After the 
head is pushed into the pelvis the patient begins to bear down, and 
sometimes complains of cramps in the legs, and desire to go to 
stool, three signs that the head is coming down into the pelvis. If 
the resistance is too much, the uterus thins out below, thickens above, 
and unless relieved will tear at the weakest part, the lower uterine 
segment. The fetus escapes into the peritoneal cavity, a serious 
acci4ent has occurred, ruptura uteri. 

If ergot has been given, or if many examinations and operations 
attempted, the irritable uterus contracts tetanically. The child is 
locked in and all operative measures rendered laborious, if not im- 
possible. 

Dangers — The dangers of contracted pelvis are protracted labor 



832 NOTES OX OBSTETRICS—SENIOR CLASS. 

with sepsis and tympany uteri, rupture of the uterus, tetanus uteri, 
pressure necrosis of the soft parts between the head and the pelvis, 
resulting in fistulae connecting the bladder, vagina and cervix, or if 
less prolonged and less severe, resulting in local inflammation, 
which binds the organs together ; further cystitis may result. Rup- 
ture of the symphysis, perhaps spontaneously; this and other in- 
juries the result of operations more or less extensive. 
Dangers to the child are — 

(a) Asphyxia — 

1. From the stasis of the blood in the maternal sinuses, 

caused by the frequent and prolonged uterine contrac- 
tions ; 

2. From partial detachment of the placenta ; 

3. From prolonged cerebral compression ; 

4. From prolapse of the cord. 

(b) Fractures of the skull, rupture of sinuses, sometimes occur 
spontaneously. 

(c) Pressure necrosis of greater or less extent on the skull. 

(d) Depression of the skull, groove or spoon-shaped depressions 
over the lateral plates of the skull, often due to the operative delivery, 
but sometimes spontaneous. 

(e) Dislocation of the bones at the base of the skull, and espe- 
cially the separation of the occipital plate from the rest of the bone, 
causing direct pressure on the medulla or hemorrhage at the base. 

(f) Cephalhematoma, often from a fissure of the bone. 
Injuries of the body are common in operative deliveries, of which 

fractured extremities are common, tearing of the sterno-mastoid, 
with hematoma, and later wry neck, paralysis of the arm, due to 
traction on and injury of cervical and brachial plexuses. 

Diagnosis of Flat Pelvis — History of rickets ; shape of the head 
(square) rosary, deformity of the long bones and of the ends, inter- 
spinous diameter equals or is greater than the intercristous, small 
Baudelocque, low pelvis, vulva looks upward, narrow sacrum, short 
C. D., prominent ischiatic spines, straight sacrum, transversely, or 
from above downward. Convex from side to side — these are the 
signs. 

Prognosis — Depends on the degree of the contraction, the size, 
the hardness of the fetal head, the number of pregnancies that have 
occurred, the condition of the uterus regarding strength and previous 
injury, the position in which the infant lies for delivery and the skill 
of the obstetric attendant. 

Treatment — Requires the highest obstetric skill, and extensive 
experience, and even with both a physician will make mistakes. In 
contractions of the mild degrees, down to 9 cm. (i. e., a C. V. of 9 
cm.) little is needed unless the child be large, or there is an abnor- 



NOTES ON OBSTETRICS— SENIOR CLASS. 333 

mal presentation, which is not seldom. Expectancy, general hygienic 
treatment and patience is all that is needed, but one must watch both 
mother and babe carefully. Hofmeier has recommended in these 
cases to press the head into the pelvis by direct pressure on the fore- 
head and occiput from outside — a little hazardous if the lower 
uterine seg-ment is thinned. In the cases of greatest contraction 
there is likewise no particular difficulty in deciding what to do. 
When the C. V. is less than 6 in a flat and less than 6^^ in a gener- 
ally contracted pelvis, the indication is absolute — Caesarean Section. 
In pelves where the C. V. is from 6 to 9 we have many measures to 
consider : 

(a) Expectancy; (b) prophylactic version; (c) symphysioto- 
my; (d) Caesarean section; (e) high forceps; (f) craniotomy. 

Expectancy — Is used when the disproportion is not great, when 
the head is soft and easily moulded, the presentation and position 
normal, in primiparae with strong pains and when the patient is in 
good condition in every way. If the pelvis is moderately small it is 
sometimes surprising to see what nature will do. 

Prophylactic version is hard to decide upon. (See later, Podalic 
version in head presentation). If previous labors have shown that a 
full-sized baby can get through the pelvis, unmutilated but not alive, 
in going- head foremost, one may do prophylactic versioft in the 
present labor. If the head is not engaged and there is indication for 
delivery, version. Abnormal presentations indicate version. One 
may, if there is tirne, induce labor a few weeks before term, when 
a head presentation is better. 

Symphysiotomy — ^See chapter Symphysiotomy. 

Caesarean Section — See chapter Caesarean Section. 

High Forceps — In some cases of labor in contracted pelvis, the 
head comes into the pelvis with a large segment and the uterus 
grasps the fetus closely so that it cannot be turned. Here we stand 
before the alternatives — Symphysiotomy, Caesarean Section, Crani- 
otomy. Craniotomy as a primary operation on a living child is not 
to be thought of. Caesarean section in a woman who is in poor 
condition — long labor, many examinations, etc. — is too dangerous. 

Symphysiotomy may be considered if both mother and baby are 
in good condition. As a rule, experience has shown this to be the 
case ; the accoucheur finds a head will not come into the pelvis ; he 
allows the favorable time for version, and for Caesarean section to 
slip by. After a variable period (usually too soon) he essays the 
forceps ; it fails ; now there is nothing left but craniotomy or symphy- 
siotomy. 

If it is found after sufficient time for moulding has been given, 
that the head v/ill not entej the pelvis, symphysiotomy should be 
proposed. If this is rejected, then a trial with the axis traction for- 



334 NOTES ON OBSrETRICS—SENIOR CLASS. 

ceps is in order. (See appropriate chapter.) If the forceps fails 
there is nothing but craniotomy. 

Sometimes one makes arrangements for symphysiotomy, then ap- 
pHes forceps tentatively ; if it fails the instrument is left on, the 
pubic joint opened and the infant delivered. 

The axis traction forceps, in these cases, is an instrument of trial 
only. 

Craniotomy is done in all cases where the child is dead, or dying, 
and as a last resort in delivery by other methods. 

Generally Contracted Pelvis — This pelvis is not uncommon in 
its milder degrees, but rare in the graver contractions unless com- 
bined with the rachitic pelvis. It is a pelvis, small more or less even- 
ly in all its diameters, but presents, too, some indications of the in- 
fantile form. May occur in large women, but usually in small. The 
bones may be thicker than normal, or perhaps gracile. In the former 
we get large external measurements and small internally, in the 
latter both are small. The sacrum is narrow, long, and higher in the 
pelvis. The anterior-posterior diameters are usually more contracted 
than the others. The diminution of the capacity of the pelvis is usu- 
ally uniform all the way from the inlet to the outlet, which has 
great significance in the mechanism of labor. 

The head enters the pelvis strongly flexed, even early in labor. 
Pains usually slow, because of slight pressure on the lower uterine 
segment, and the uterus is often- infantile as well as the pelvis. 
Labor is tedious because the head meets with resistance all the way 
down, and has to be moulded to extreme dolichocephalia. 

Diagnosis — This is not easy. INIeasurements only indicate the 
condition. Palpating finger learns by experience to estimate the size 
of the cavity. 

Prognosis — Usually good unless contraction is marked; when 
there are the same dangers as in flat pelvis. Danger from pressure 
necrosis not so great, but there are dangers from the operative de- 
livery so often needed. 

Treatment — Version is not usually a good operation, because 
there is no room at the sides of the pelvis into which the head may 
be squeezed, while passing the narrow C. V. Forceps — dangerous 
to mother and child ; almost equal to craniotomy. See treatment of 
flat pelvis. 

Diiferent Forms — A combination of flat and generally contracted 
pelvis occurs in rachitic women. Generally the pelvis is small, thin 
and almost always asymmetrically deformed. Labor presents par- 
ticularly great difficulty and irregularity of mechanism common to 
both forms of pelvis. 

Spondylolisthesis is a pelvis in which the last lumbar vertebral 
body has slid down over the sacral body into the pelvis. Due usually 



NOTES OX OBSTETRICS—SENIOR CLAS^. 335 

to injury or cong-enital malformation of the interarticular process 
of the vertebra. 

The funnel-shaped pelvis deserves more attention than it receives. 
This is a female pelvis of the masculine type. The sacrum curves 
forward, the tuberosities of the ischia riui inward a little, the pubic 
arch is narrow, the outlet is narrow like a man's. This form of pel- 
vis is more common than is generally believed and gives rise to delay 
in labor at the end of the second stage, to obstruction, of rotation of 
the head, and may give trouble in delivering the shoulders. 

Diagnosis — This is not hard. Two measurements of Breisky, 
distance betw^een tuberosities of ischia, and from end of sacrum to 
subpubic ligament, also the distance between the spines of the ischii 
taken by means of the author's outlet pelvimeter. 

Treatment — Watchful expectancy. Head almost always moulds 
and goes through. If delivery indicated, forceps — symphysiotomy, 
craniotomy. 

Other pelves of interest are the kyphotic, the kyphoscoliotic, the 
osteomalaic, etc. 

THE PASSENGERS. 

The child may be too large, either as a whole or a part of it, e. g., 
hydrocephalus, ascites, anasarca. It may have a very hard head, 
which is especially important. 

The size of full term children varies within wide limits. The 
boys are larger than the girls, they have a larger bi-parietal diam- 
eter, and generally a relatively larger and more ossified head ; as a 
result more boys die during labor. The children grow larger and 
heavier in succeeding pregnancies, until the seventh or eighth, when 
the weight is uniform. The largest children are born in the 28th 
to 35th year. The bi-parietal diameter of later children is larger than 
that of the earlier ones, the difference being i to i^ cm. 

The shape and size of the father's head has something to do 
with the question, but particularly of the mother's head, so it is said 
that the child's head is a miniature of its mother's. A large, heavy 
woman usually has a large baby ; same true of short, fat women. 

Diagnosis — Of a large head is made by abdominal palpation and 
menstruation of the head directly with a pelvimeter. Cephalometr)' 
is giving better results every year. A special instrument, the cephal- 
ometer, renders it very easy. The diameter of the pelvis in which the 
head happens to be must be considered. Results are clinically useful. 

Delay in labor and all the signs and symptoms of contracted 
pelvis are caused by large and hard heads. Forceps sometimes 
needed. Prognosis not so' good for baby. 

Enlargement of the Shoulders — Girls not seldom give trouble 
here. The head comes through very well, but the shoulders are ar- 



336 NOTES ON OBSTETRICS—SENIOR CLASS. 

rested at the inlet, either by their large size or anomalous mechanism. 
The head springs back into the vulva, pressing it in between the 
tuberosities, unless delivery is soon effected the child dies of as- 
phyxia. Hard to manage because the head is in the way. 

Treatment — Have the patient bear down vigorously and aid same 
by Kristeller expression. 

2. Try to rotate the shoulders into a favorable diameter by ex- 
ternal and internal manipulation. Follow the mechanism indicated 
by nature. 

3. Bring down the posterior arm into the pelvis and draw on 
this, gently. Do not break clavicle. 

4. If last fails, bring down the anterior arm. It may be neces- 
sary, but rarely, to use brute force, and risk a fracture of the ex- 
tremities. 

If the delivery is obstructed by an hydrocephalus — puncture it; 
if by fluid in the chest or abdomen, evacuate it. If by anasarca, case 
difficult ; morcellation. 

Note — Now would follow errors of posture and abnormal pre- 
sentation of the fetus, as occipito posterior positions, deep transverse 
arrest, face, brow, breech, shoulder presentation, prolapse of the 
cord, arms, etc., but these we will take up under Operative Obstet- 
rics, q. V. Also the anomalies in the delivery of the placenta. 

COMPLICATIONS. 

A labor may be complicated at any stage, or a complicated labor 
may right itself at any stage and then proceed normally. The com- 
plications about to be considered are not connected with the powers, 
the passages or the passengers. They are extraneous, and come from 
the side of the mother and from the fetus. We will give them in no 
special order. First, those on the part of the mother : — 

PUERPERAL HEMORRHAGE. 

Pregnancy brings with it a large number of physical conditions 
which predispose to hemorrhage. The normal function of labor is 
attended with hemorrhage and there are few conditions in pregnancy 
but hemorrhage forms an important part. An obstetrician, therefore, 
must get used to the sight of blood and must have all the means of 
hemostasis at his command, both those known to surgery and those 
which form a part of his special branch. The patient has acquired, 
by a wise provision of nature, a certain immunity against fatal hem- 
orrhage, in that the amount of blood is increased and the power of 
clotting augmented, there being more fibrin. Still a large number 
of women lose their lives from puerperal hemorrhage every year. 



NOTES ON OBSTETRICS—SENIOR CLASS. • 337 

It is therefore essential that you acquire a thorough knowledge of 
the methods of controlling bleeding in obstetric cases. This is one of 
the most dangerous complications of labor, and of the dangerous 
complications is the most common. 

The possibility of hemorrhage begins with coitus. Cases of se- 
vere and even fatal hemorrhage from rupture of some vessel of the 
hymen or clitoris are on record. 

During pregnancy the patient may have bleeding from ruptured 
varices of the vulva and this may be fatal. The rupture is due to 
excessive pressure and necrosis, or to wounding by scratching (be- 
cause they itch) or from using a broken vessel. 

The most common cause of hemorrhage in the early months of 
pregnancy is abortion. Threatening abortion manifests itself by pain 
and hemorrhage. In a few cases the pains cease, the bleeding also, 
and the pregnancy goes to term ; more usually after a few weeks or 
days the hemorrhage recommences and the abortion takes place or the 
bleeding becomes so severe that operation is necessary. Very rarely 
the bleeding may continue several weeks. In the latter cases you 
must suspect myxomatous degeneration of the chorion, etc. This also 
causes bleeding, but there is more often a discharge of watery, 
bloody fluid and then the grape-like bodies. 

In the latter months of pregnancy hemorrhage acquires much 
greater importance. There are three conditions attended with hem- 
orrhage in the last three months of pregnancy, which must be borne 
in mind: 

1. Placenta previa. 

2. Premature detachment of the normally implanted placenta. 

3. Sometimes beginning miscarriage shows itself thus, or a 

placenta marginata, but usually in these cases hemor- 
hage is a minor symptom. 

PLACENTA PREVIA. 

This condition formerly had a very high mortality rate, both for 
the mother and for the child. The outlook for the mother is now 
much better, if the proper treatment is done, but the percent, of 
deaths of the children is still high. There is also a difference be- 
tween private practice and the hospitals, the mother standing a bet- 
ter chance in the hospitals. (Ahlfeld, 75% in private practice.) 
This improvement has been brought about since the Braxton Hicks 
version has been done in these cases. For a time the child was not 
considered at all, but recently the importance of the life of the 
child has been accorded more value in all cases, and also here, so 
that there is a diminution also of the infant mortality. Still, as a 



338 NOTES ON OBSTETRICS— SENIOR CLASS. 

general rule, unless you have things your own way, and the case 
well in hand, treat the child secondarily. 

Causation — Placenta previa occurs once in i,ooo cases, but here 
there is the usual trouble in getting statistics. It is much more rare 
in primiparae (i:io) than in multiparae. 

Predisposing Causes — 

(i) Catarrhal endometritis the usual cause, and it need not 
necessarily be of marked degree. 

(2) Dilatation of the cavity of the uterus, perhaps from catarrhal 
endometritis, or more frequently from subinvolution, or the two may 
go together. Has been noted that cases of placenta previa occur 
frequently in women who had had a placenta removed manually 
in previous labors (may he due to endometritis). Previous abor- 
tions ; loss of the cilia through inflammation. 

(3) Habit — Placenta previa has been known to recur seven 
times. Cases of three occurrences are not rare (may be due to the 
continuance of the endometritis). That the endometritis really plays 
such an important part is demonstrated by the findings on the pla- 
centa, white infarct, especially placenta marginata, thickened decidua, 
etc. 

Acting Causes — 

(i) Primary insertion of the ovum low down. Owing to the 
size of the uterine cavity or to the diseased slippery endometrium, 
the ovum finds no favorable point for adhesion ; it slips down to the 
internal os ; here the decidua has grown up and it comes to rest 
there. 

(2) Hofmeier and Kaltenbach's view : That the decidua sero- 
tina does not offer enough surface for the nutrition of the ovum 
and the chorionic villi therefore grow in the decidua reflexa. Later, 
the decidua reflexa comes to be applied to the decidua vera, and may 
lie over the internal os. Many things in favor of this theory, but it 
presupposes a primary low insertion of the tgg, and this may ex- 
plain the lack of nutrition of the serotina. These two theories ex- 
plain the large number of the cases, but a few other conditions de- 
serve mention. The tubes in one case were found to insert in the 
lower uterine segment. 

Deiinition — Placenta previa is the development of the placenta 
in toto or in part, in the lower uterine segment. Depending on 
the extent of the lap over the internal os, we speak of placenta previa 
marginalis, when just the edge of the placenta is palpable in the os ; 
placenta previa lateralis, when one-half of the os is covered by pla- 
centa — placenta previa centralis when the finger feels placental tis- 
sue all around. Of course, a placenta previa centralis may become 
lateralis when the os dilates more, or a lateralis may appear more 
marginalis. Thus the terms are relative, and clinical. 



NOTES ON OBSTETRICS—SENIOR CLASS. 339 

. Some authors distinguish complete and partial placenta previa. 
The most prominent symptom of placenta previa is hemorrhage. 

Hemorrhage — This is at first usually slight, occurs in the later 
months of pregnancy and is accompanied by uterine contractions. 
These may be felt by the palpating hand, but not by the patient. 
The severer the hemorrhage, the surer is the occurrence of labor. 

How to explain the hemorrhage has not been definitely settled. 
During the latter months of pregnancy, owing to the painless uter- 
inte contractions, the lower uterine segment is being formed. This 
causes a retraction of the fibres of the lower uterine segment, by 
which they are drawn up to form part of the body of the uterus. 
The placenta does not grow so rapidly that it can keep pace with 
the retraction of the lower uterine segment, therefore the place 
of the insertion gets larger than the placenta and a slight separation 
takes place. This, of course, becomes most marked during the first 
stage of labor. If the bag of waters is ruptured, the placenta can 
lie flat on the wall of the lower uterine segment, and can be drawn up 
with it, becoming, so to speak, part of the lower uterine segment. 
This explains the cases of spontaneous cessation of the hemorrhage 
when the bag of waters ruptures. It is easily seen that the hemor- 
rhage is the result of factors over which we have no control, and 
the hemorrhage has been called "unavoidable," to distinguish it from 
the premature detachment of the placenta, which is ''accidental" 
hemorrhage. Still, we cannot eliminate trauma. Owing to the ex- 
posed position of the placenta, a slight trauma, as straining at stool, 
or coitus, may bring on the bleeding. Further, the low situation of 
the placenta, so near the infected vagina, predisposes to inflammatory 
adhesions of the placenta, and finally even to infection after the 
third stage. Two important points. The hemorrhage comes almost 
entirely from the mother, the separation occurring at the expense 
of the mother, it is the maternal blood vessels that are opened. The 
fetus may also bleed if by a careless examination some of the ves- 
sels in the placenta are torn. But usually the fetus dies of asphyxia, 
from compression of the placenta, especially at the insertion of the 
cord or because the blood of the mother, who has bled so much, 
cannot supply it with enough oxygen. 

In cases of placenta previa centralis the separation is earlier in 
pregnancy ; therefore, hemorrhage earlier, and is more extensive ; 
therefore, hemorrhag-e greater ; which are clinical facts and which 
make the prognosis worse in these cases. 

Clinical History — It is possible that many cases of abortion are 
cases of placenta previa, the exposed position of the ovum tending 
to make it more susceptible to accidents. 

The main symptom is hemorrhage. Some time after the seventh 
month there is painless uterine hemorrhage. It may or may not 



340 NOTES ON OBSTETRICS—SENlOR CLASS. 

be accompanied by uterine pains. The causeless nature, its sudden- 
ness and the absence of any pain are so marked, that the combina- 
tion is characteristic. Therefore, sudden, painless, causeless hemor- 
rhage occurring in the last three months of pregnancy, is almost 
always placenta previa. * 

The first hemorrhage is usually slight and ceases, the patient 
going about her affairs. After an interval of two weeks, sometimes 
earlier, there is a repetition of the bleeding. This time it is more 
severe and may be fatal, or the first hemorrhage may be fatal. This 
usually depends on the insertion of the placenta. If central, the 
hemorrhage is severer and occurs earlier. In certain cases there is 
a continual oOzing of blood which may not appear alarming, but 
which brings the patient into a very anemic condition and makes her 
very susceptible to even a moderate loss of blood at labor. This is 
called stillicidium sanguinis.' 

With the second hemorrhage labor usually begins. Rarely a 
second interval. The patient may go to term, and after the labor 
the placenta is found altered, where it hung down into the lower 
uterine segment, into a hard membranous lap resembling a blood 
mole. These are cases of spontaneous cure of placenta previa. They 
are rare and are not to be counted on in practice. 

In cases of marginal placenta previa there may be a sHght 
hemorrhage just before the bag of waters ruptures, but no other 
symptom during the labor. After the labor the placenta is found 
to have been very near the internal os, its edge having been over- 
looked. The prognosis is good for both mother and child here. In 
the other cases unless aid is rendered the woman, she and her off- 
spring die. The hemorrhage that is the least is the first, and each 
succeeding one is severer, but the first may be very serious. 

Diagnosis — Sympioms-^S ltd den, painless, causeless uterine hem- 
orrhage, in the latter months of pregnancy. 

Findings Abdominally — May feel soft body over the head in the 
inlet. Reliance not to be placed on it. Right side more usually in- 
volved. 

FINDINGS VAGINALLY. 

Boggy feeling in the vaginal vault, great succulence of the parts. 
Head felt indistinctly, as though it were through a flat sponge, or 
felt plainly on one side and thickly on the other. Pulsating arteries 
have but little significance. Breech or a shoulder may give the feel- 
ing of a soft body. Only certain diagnostic sign is the feeling of the 
spongy placenta, through the internal os. The only conditions that 
could simulate the feel of a placenta are thick vernix caseosa on the 
head, some monstrosity presenting an uneven surface, thick mem- 



NOTES ON OBSTETRICS—SENIOR CLASS. 341 

branes. or hemorrhage between the two membranes, and a blood clot. 
If you keep these in mind such mistakes will not occur. In some 
cases you feel only the thickened membranes over the internal os 
and have to go up the side to feel the placenta. Palpate gently so 
that you do not tear the placenta and cause fatal hemorrhage. The 
head is usually not engaged, being prevented by the bulky placenta. 

Prog}ios{s — Formerly 25% to 30% of the mothers died, either 
from hemorrhage or sepsis and occasionally from air embolism. Now 
the maternal mortality, owing to better treatment, has been reduced 
to 4%. Hirst, 1%. If you have a case from the start, w^here the 
W'Oman has lost only a small amount of blood, she should not die, 
unless by some accident, e. g., air embolism. The greater tendency 
to sepsis should be remembered, because the placental site is so near 
the vagina and because of the many and rough manipulations neces- 
sary. 

For the fetus the prognosis is bad, 50% to 75% die. 

First, they are generally prematurely born and may die in the 
first days of life ; second, the means of controlling the hemorrhage 
are often such as to compromise the life of the fetus by pressure 
on the placenta, tearing the placenta, slow extraction ; third, there 
may be slight hemorrhage (fetal), and the fetus illy affords a loss 
of blood, however small ; fourth, displacement of the placenta be- 
fore or with the child at a time when the cervix does not permit im- 
mediate deliverv-, and warns against forcing the dilatation and ex- 
traction. 

Treatment — The treatment of placenta previa has become much 
more rational and certain than that of any severe obstetrical com- 
plication. This cannot be said of eclampsia. Here the treatment 
is still uncertain. , 

Definite principles in the conduct of these cases may now be laid 
down. 

The prophylactic treatment of placenta previa is of importance 
but cannot be carried out, because the case usually occurs among 
the poor people. Cure endometritis. 

Dr. W. W. laggard made the following propositions, w^hich I 
have found very good guides in practice : 

(I) There is no expectant plan of treatment for placenta pre- 
znu. Since the child is almost ahvays viable, there is no excuse 
for w-aiting. The hemorrhage is "unavoidable." It may occur in 
the night, and the woman may die before aid can reach her. 

(II) Physician s ditty to stay by his patient till she is delivered 
and out of danger. Somebody must be at her bedside till all danger 
is past. 

As soon as the diagnosis is made, two propositions must be laid 
before the patient and her family : First, she must submit to the 



342 NOTES ON OBSTETRICS—SENIOR CLASS. 

induction of labor ; second, she must go to a well appointed hospital 
and await there, in bed, her confinement, it being understood that if 
at any time the hemorrhage becomes profuse the pregnancy is to be 
interrupted. If she assents to neither proposition, it is advisable to 
drop the case. If the bleeding stops or becomes insignificant, one 
is encouraged in waiting, but a hemorrhage that recurs more than 
twice, where clots are passed, requires interference. If, then, labor 
does not come on itself, it must be induced. I prefer to begin in the 
A. M. (unless there is indication to interfere without delay), punc- 
ture the bag of waters, put in a colpeurynter, draw on same and 
stay by the patient till all danger is over. If the woman is found 
bleeding profusely, labor having started, the following is the course 
to pursue : 

The aim of the treatment is : first, to stop the hemorrhage ; sec- 
ond, to empty the uterus ; third, to get retraction and contraction 
of the uterus. The method of treatment to pursue depends on the 
state of the cervix. 

(I) If effaced and os dilated the proper treatment is to rup- 
ture the bag of waters and extract. If conditions for forceps are 
present, use it ; if the breech presents, extract by the breech. If 
the head is movable above the inlet, version, and extraction ; if there 
is an indication when the version is completed. Be sure the os is 
completely dilated. 

(II) If the cervix will just admit two fingers, and this is the 
usual case, there are two methods of treatment. 

The first, the oldest, and a thoroughly reliable method, is : Rup- 
ture the bag of waters, do Braxton Hick's version, bring down 
a foot till the breech is well into the lower uterine segment, then sur- 
render the case to nature. Do not attempt to extract, because you 
will tear the cervix to the peritoneum, and then the death of the 
mother is certain (from hemorrhage). Even a slight or a super- 
ficial tear when the placenta is inserted in the cervix is of serious 
moment, as the placental uterine sinuses being superficial and the 
retractile power of the lower uterine segment being slight, a tear 
of one of these large blood vessels results in a furious and obstinate 
hemorrhage, w^hich, in a woman already anemic, is more easily 
fatal. 

After bringing down the leg, the breech tampons the lower 
uterine segment, prevents further bleeding, and also elicits pains, so 
that labor is spontaneously terminated in a few hours. If the 
hemorrhage should recommence, pull down a little on the breech and 
may repeat this. This method of treatment is an excellent one, but 
the chances for the fetus are quite small. 

Second Method — Is the intra-uterine colpeurysis, first employed 
by Maurer and improved by Diihrssen and Champetier de Ribes, 



NOTES ON OBSTBTRICS—SENIOR CLASS. 343 

particularly Diihrssen : Rupture the bag of waters and pass the 
Carl Braun colpeurynter inside the membranes. Now inject one- 
half pint of some weak antiseptic solution, clamp and attach a tape 
with a bottle hanging over the foot of the bed so as to regulate the 
amount of tension. This is about two pounds, often one pound, is 
enough. This acts like the breech, presses the placenta against the 
lower uterine segment, elicits pains, stops hemorrhage, dilates cer- 
vix. Watch the patient carefully. The bag may elicit too strong 
pains, which endanger the uterus. After thirty minutes to two 
hours, the bag is expelled. The cervix is now large enough to do 
a version, and this should be done ; or the bag may be re-introduced 
and dilated so large that when it is expelled the passages are suf- 
ficiently dilated to admit the immediate delivery of the child. Some 
accoucheurs put a bag in the vagina to dilate it also. In lateral 
placenta previa these manipulations are made through the opening 
in the membranes. In central placenta previa the opening must be 
made through the placenta. This, of course, makes a bad prognosis 
for the child. 

(Ill) In primiparae, placenta previa is luckily quite rare, but 
when it occurs it is a most formidable condition. The reason is 
that the tight cervix, vagina and vulva are bad hindrances to the 
proper treatment. If the cervix is not dilated enough to get in the 
Braun's Colpeurynter (Diihrssen has succeeded in doing this when 
he could just get the index finger through), you must stop the 
hemorrhage till the cervix is at least dilated for two fingers. Two 
methods : Vaginal Tampon and Colpeiirysis. Of the two (both are 
bad because of the danger of sepsis and incomplete hemostasis), the 
tampon is the better. Do not leave it longer than eight hours. 
It is hard to apply properly, hard to keep aseptic, and still may 
allow internal hemorrhage or oozing alongside the tampon. There- 
fore, do not leave the patient, trusting to the tampon. Put on a 
tight abdominal binder to force the uterus down on top of the tam- 
pon. After the os has dilated the treatment is the same as given. 

Other treatments : e. g., dilate the cervix by Barnes' bags. Vagina 
with colpeurynter. Perhaps head may come into the pelvis, then 
hemorrhage stops, then leave case to nature. If placenta marginalis, 
puncture bag of waters and wait ; if no hemorrhage, all right : if 
there is after this, same treatment as before given. Caesarean section 
is recommended for cases of central placenta previa, at term, with 
living child, under favorable conditions. 

Treatment During Third SHage — The treatment during the third 
stage is highly important. Owing to the inflammatory conditions 
during pregnancy, the placenta has usually become somewhat ad- 
herent to the lower uterine segment, and may, therefore, give rise to 
severe hemorrhage and the retention of pieces of the placenta. Fur- 



344 NOTES ON OBSTETRICS—SENIOR CLASS. 

ther, the lower uterine segment is not so well provided with muscu- 
lar fibres and, therefore, the placental site does not retract and close 
off the vessels ; therefore, greater hemorrhage from uterine atony. 
Finally, during the extraction, which might have been undertaken 
too soon, the cervix may have been torn, and from here we get the 
worst hemorrhages. The soft vascular cervix is more likely to tear 
and these tears bleed very profusely, because the vessels of the pla- 
cental site are so large and numerous. 

Hemorrhage after the expulsion of the placenta, therefore, is 
due to cervix tear or from atony uteri. A woman who bleeds and 
whose uterus is hard, generally has a cervix tear (or a vulva tear). 
Examination will show this. Sew up the tear or pack the uterus, 
the lower uterine segment, and the vagina tightly with lysol gauze. 
Pack soon, i. e., don't waste time trying inefficient kinds of treat- 
ment. Treat the anemia. This will be considered under post partum 
hemorrhage. 

During the puerperium there is greater tendency to infection : 
1st, because of the necessary, continuous and sometimes violent 
manipulations during delivery ; 2nd, because of the exposed position 
of the placental site, — near the septic vagina ; and, 3rd, the anemia 
of the w^om_an weakens her resisting powers. Therefore, be extra 
careful. 



PREMATURE DETACHMENT OF THE NORMALLY IM- 
PLANTED PLACENTA. 

The placenta is normally inserted near the fundus uteri, on the 
anterior or posterior wall, seldom in the fundus, but seldom on the 
side; more often posteriorly than anteriorly. The normal separa- 
tion of the placenta is attended with hemorrhage, but when the uterus 
is emptied, or even when it can contract down well on the placenta, 
there is no further bleeding. Should the separation occur during 
pregnancy, while the child is still in utero, this contraction of the 
organ is not possible and, therefore, the woman bleeds interruptedly, 
either internally or externally. The accident is quite rare. Up to 
1870, Goodell, of Philadelphia, collected 106 cases (of which 54 
mothers died). Since then cases have been published more frequent- 
ly, so that it is probable that the cases are occasionally overlooked. 
I think it is not so rare, have had 12 cases. 

Causes — 

(i) Chronic decidual endometritis: The blood vessels are 
fragile (which is true even of the healthy decidua), and sometimes 
slight trauma ruptures one. The slight hemorrhage started leads 
to a larger one, till the whole placenta is separated, 



NOTES OX OBSTETRICS—SENIOR CLASS. 345 

(2) Chronic nephritis. With numerous white infarcts. Chronic 
peritonitis has been demonstrated. Under this head would also 
come acute infectious diseases, because of the numerous hemorrhages 
in the maternal decidua. 

(3) Irregularities of the circulation; e. g., Morbus Basedowni 
said that even excitement will do it; usually some pathological con- 
dition at base. 

(4) Trauma — Fall, turning in bed, striking against a table ; but 
there is generally some pathological condition of the decidua, which 
predisposes to it, or the placenta may be on the anterior wall and 
exposed, 

(5) During the delivery of the trunk in breech presentations 
there is a separation of the placenta. Also, after first twin, the 
common placenta may be displaced and the second fetus die of as- 
phyxia, French authors mention a too short cord. Seems to be 
some relation between this accident and rupture of the uterus from 
the peritoneal side. 

Symptoms — The severity of the symptoms depends on the 
amount of hemorrhage, and this depends on the degree of separa- 
tion. As a rule, the case appears alarming from the start and medi- 
cal aid is summoned early. 

Sudden pain in the abdomen usually located where the placenta 
is, on the right or left side, generally the right. Distension of the 
uterus and abdomen ; cessation of fetal movements and heart tones ; 
signs of anemia rapidly develop and become severe ; collapse in bad 
cases. Woman may bleed to death without one drop of blood ap- 
pearing externally. The placenta may lift itself up in the middle, 
remaining adherent by the edges, and there is room for a large 
amount of blood which makes a prominent tumor on the outside 
of the uterus. Later, the blood can work its way down between the 
membranes and the uterus, appearing externally. Or the bleeding 
may take place into the liquor amnii, the membranes having ruptured 
over the clot. This is denied by some authors, but it is possible. 
The uterus is immensely distended by the blood and the patient may 
perish ; or, the hemorrhage may be entirely external (good prog- 
nosis). Sudden increase in the size of the uterus, tension of the 
abdominal parietes, acute pain referred to the placental site, and 
after a while hemiorrhage externally, with the general symptoms 
of a more or less severe anemia, constitute the classical symptoms 
of this accident. This is the so-called ''accidental" hemorrhage. 
The placenta may prolapse and come to lie over the internal os, 
making diagnosis difficult. 

The symptoms of hernorrhage are : Faintness, dizziness, short- 
ness of breath ; patient yawns or sighs frequently ; praecordial anxietv 



346 NOTES ON OBSTETRICS— SENIOR CLASS. 

and oppression, palpitation, ringing in the ears, spots before the 
eyes, or patient sees everything black ; thirst. 

Signs — Patient pale, prostrate, white gums, eyes fallen in, pearly 
conjunctiva, cold extremities and nose, which perhaps is bluish; 
pulse rapid and weak and compressible. Later, fainting, vomiting, 
unconsciousness, delirium, followed by convulsive movements. Ex- 
cessive thirst, cramps in the muscles and fainting are bad symptoms ; 
then, when the urine and feces are discharged involuntarily, the pa- 
tient soon gets a few convulsive spasms and dies. 

Diagnosis — Lies between ruptured uterus; placenta previa and 
extra uterine pregnancy. Examination of the abdomen excludes 
the first and the last. Symmetrically large, tense, painful, uterus, ex- 
cludes them. The history, the severity of the pain, the presence of 
the uterus one side and the child free in the abdominal cavity, shut 
out rupture of the uterus. Internal examination will show uterus 
small and empty in extra uterine pregnancy and rupture of the 
uterus. 

Placenta previa is excluded because you feel no placenta over 
the internal os. Usually diagnosis is difficult, unless case known 
before. May need abdominal section to prove conditions and cure. 

Prognosis — Worse than placenta previa. Goodell, 54 from 106 
mothers and only six living children. Later statistics are -not so 
bad. Danger to mother is hemorrhage, and the severe operations 
necessary. Dangers' to the child are asphyxia from separation of the 
placenta. 

ACCIDENTAL HEMORRHAGE, PREMATURE 
DETACHMENT OF PLACENTA. 

Symptoms. 

1. Sudden severe onset. i. Rather quiet onset. 

2. Pain, generally referred to 2. No pain, unless uterine con- 

placental site. traction, 

3. Hemorrhage, internally or ex- 3. Hemorrhage always external 

ternally, after a while. at start. 

4. Hemorrhage, severe, — inter- 4. First hemorrhage generally 

nal or external. mild. 

5. Only one hemorrhage usually. 5. Several, or history of several. 

6. May find a cause, — injury, 6. Usually no cause, may be. 

jar, etc. 7. Symptoms proportionate to 

7. Symptoms of a severer hemor- the amount of blood lost ex- 

rhage than the amt. of blood ternally. 

externally shows. 8. No change usually. 

8. Cessation of fetal movements. 



NOTES ON OBSTETRICS—SENIOR CLASS. 347 

UNAVOIDABLE HEMORRHAGE. PLACEN- 
TA PREVIA. 

Signs. 

1. Abdomen distended, tense and i. Abdomen as usual at cime of 

painful. pregnancy. 

2. Uterus tense, can't fee! fetus. 2. Uterus soft unless there is 

3. Fetal heart tones absent. pain. 

4. Vaginally, no placenta over 3. Almost always present. 

internal os. 4. Placenta over os. 

5. Bag of waters tense, — feel 5. Bag of water loose ; usually 

hard. head not engaged. 

Treatment — Of premature detachment of the placenta. Cannot 
formulate hard and fast rules, as in placenta previa. In general, 
the best treatment is that which empties the uterus quickest and 
with least danger to the mother. Object is to empty uterus as quick- 
ly as possible, to enable it to close off the bleeding vessels. Secondly, 
you must treat the anemia. 

(a) If the cervix is effaced and the os dilated, extract the child 
either after version or by forceps, if the head is engaged ; labor al- 
most always commences and proceeds rapidly. 

(b) If the OS is not dilated, put in a Barnes' bag, give the patient 
ergot, ^ dr., every 20 minutes ; tight binder ; hand on uterus and 
pulse. 

(c) If hemorrhage continues, puncture bag of waters. 
Dangers are : 

1st. There is now more room in the iiterus and it is filled up with 
blood. 

2nd. The sudden loss of the fluid may be just enough shock to 
turn scale against woman. 

3rd. The bag of waters being gone, the cervix dilates poorly, 
and all operation made difficult. 

Do intra-uterine colpeurysis. Give ergot. No vaginal tam- 
pon. 

(d) If the situation is grave, saline solution under the skin, di- 
late OS with colpeurynters, and Barnes' bags, or the fingers, incise 
the cervix laterally, deliver and stand ready for all complications. 
Bad cases ; consultation. Explain to the family. 

Caesarean section proposed as a method to rapidly deliver the 
patient, and avoid all dangers from delayed vaginal delivery ; also, 
vaginal Caesarean section. Both may be used in selected cases and 
proper surroundings. 

Other Forms of Henw'rrhage — A form of hemorrhage that some- 
times occurs at the time of rupture of the bag of waters has its 






348 NOTES ON OBSTETRICS—SENIOR CEASS. , 

origin in a tear of one of the vessels of a cord that is inserted into 
the membranes, i. e., velamentous insertion of the cord. The tear 
in the bag of waters extends throiigji one of these vessels if they 
should happen to lie across the internal os. Of course, the danger 
is entirely fetal, and death occurs from hemorrhage. If the child 
is born quickly it may still come living, but usually it dies as a 
result of this anomaly. Diagnosis may be made if vessels are felt 
in the membrane before they rupture. Rarely done, but may need 
to differentiate the forelying cord. If diagnosis made before rup- 
ture, delay the rupture of the bag of waters as long as possible, 
i. e., by the colpeurynter. When the cervix is ready, rupture bag 
of waters, and extract quickly. After rupture, the condition may be 
suspected by the hemorrhage, wdiich comes with the liquor amnii. 
If the child is dead, await natural termination of labor or perforate. 
Happily, the cases are rare. 

During labor another form of hemorrhage occurs. It is due 
to the loosening of the placenta from a too sudden evacuation of the 
liquor amnii. During the pain a small amount of blood is forced 
out, or some blood-stained liquor amnii. When the head is pushed 
up, blood flows down into the hand. Cases are quite rare because 
the placenta can generally accommodate itself to the diminished size 
of the uterus. The condition and its treatment are similar to pre- 
mature detachment of the normally implanted placenta. 

The loosening of the placenta is a cause of asphyxia and still 
birth, the child dying during a prolonged second stage. These 
deaths are actually preventable and the accoucheur is responsible. 
Watch the heart tones during the second stage. 

Another form of hemorrhage during the latter part of pregnancy 
is from rupture of the circular sinus of the placenta. Blood comes 
from the mother. Not dangerous. Diagnosis difficult, usually by 
exclusion. Treatment of the same as for premature detachment. 

POST PARTu:\i he:morrhage. 

The loss of blood during labor varies from 225 to 300 grammes, 
but may go as high as 500 without being pathological or making 
any effect on the condition of the woman. A loss above a pint is 
pathological. Bloodless labors are very rare, are not normal, and 
are usually found where the fetus has already been dead a long time 
and thrombosis of the placental site has occurred. Cases of leukemia 
also are said to be bloodless. When the blood gushes from the vul- 
var orifice, or oozes steadily after the placenta is expelled, the case 
is pathological. During the first two hours after labor a puerpera 
should not lose over two ounces of blood. Normally, the placenta 
begins to separate while the last parts of the child are leaving the 



NOTES OA' OBSTETRICS—SENIOR CLASS. :U9 

uterus. There are three factors which bring about this separation : 
(I) The retraction and contraction of the uterus, the lessening of 
the area of the placental site. (2) The formation of the retro- 
placental blood, clot. (3) Gravity, to a sUght extent. x\t the end 
df 15 to 30 minutes, the placenta is almost always separated and 
has dropped down into the lower uterine segment. The blood ves- 
sels of the placental site have been torn across in the line of separa- 
tion. The hemorrhage is prevented by : 

(i) The retraction of the muscular fibres and the super- 
imposition of the muscular lamellae on each other. 

(2) Thrombosis of the veins, and, to a less extent, the arteries. 

This is called "puerperal thrombosis," and extends only a short 
distance into the uterine wall. If the thrombi pass through the 
uterine wall the thrombosis is pathological. The thrombosis is less 
important, since in some cases of puerperal fever the clots are dis- 
solved and there is but rarely any hemorrhage. 

Anomalies of retraction and contraction are the more usual 
causes of post partum hemorrhage, the thrombosis, except in cases 
of hemophilia, being usually present; but if the uterus fails to con- 
tract, the thrombosis will rarely stop the hemorrhage. Cases of 
really severe post partum hemorrhage are rare. Impossible to get 
statistics. They are mostly errors of art. Statements made that all 
cases of post partum hemorrhage can be prevented is not true. The 
cases are rare where the bleeding cannot in a great measure be pre- 
vented, or at least the patient be saved from death. 

Causes — 

(i) Laceration of the vulva, vagina, cervix. These are the 
causes more often than is thought, the hemorrhage being ascribed 
to uterine atony. The uterus has great power of contraction and 
will contract even after the death of the mother, but still atony may 
be the cause. 

(2) Uterine Atony — This is due to : (a) Precipitate labors, 
therefore post partum hemorrhage, common in multiparae. (b) Too 
rapid extraction, by forceps, breech or after version. The too rapid 
emptying of the cavity of the uterus ; it must have a little time to re- 
adapt Itself to the diminished cavity. Paralysis of the placental site. 

(3) Primarily weak pains. Either due to some malformation of 
the uterus, double or single-horned uterus, maldevelopment of the 
uterus, or to some tumor in the uterus causing faulty contractions, 
pre-eminently uterine fibroids, uterine adhesions, or to the general 
weakness of the" mother. Uterus fatigued from long labor. Well- 
known clinical fact that post partum hemorrhage occurs usually in 
weak women and not so often in the strong, robust working women. 

(4) Too frequent pregnancy. This weakens the uterine con- 
tractile power. 



350 NOTES ON OBSIETRICS—SENIOR CLASS. 

(5) Excessive dilatation of the uterus, twins, hydramnion. 

(6) Habit. No definable cause. Probably chronic endometritis 
or metritis. 

(7) Too hasty expression of the placenta. Interference with the 
normal progress of the third stage. In these cases the rough manip- 
ulation forces out the clot, the placenta may not be fully separated 
and hemorrhage results. 

(8) Partial adhesion of the placenta, or retention of a clot or a 
piece of placenta or thick membranes. 

A rare cause of post partum hemorrhage is hemophilia. That 
all bleeders do not die of post partum hemorrhage is shown by the 
fact that bleeders propogate their kind. If the mothers died in child- 
birth the family would soon be exterminated, since the tendency is 
said to be transmitted on the mothers' side. Said that chloroform 
and quinine predispose to hemorrhage ; some truth in it, also in some 
blood dyscrasia, e. g., malaria, syphilis. 

Diagnosis — This is of great importance. Must distinguish first, 
when the placenta is in the uterus, and after the expulsion of the 
placenta. We find two conditions with hemorrhage during the third 
stage : 

(A) The uterus is large, soft, near the liver, doughy, hard to 
find. These cases are usually where there is a large placenta, and 
there has been a precipitate labor, or where there is a total or par- 
tial adhesion of the placenta. The hemorrhage may be entirely 
internal, and exit of the blood being prevented by the bend in the 
cervix, due to the extreme anteflexion of the uterus, to the covering 
of the cervix by a blood clot, or a piece of membrane. 

(B) The uterus may be hard, well contracted. In these cases, 
which were formerly called ''hour-glass contraction" of the uterus, 
the placenta may be adherent in part, but more often incarcerated. 
Uterus below level of navel. Traction on cord would pull down 
uterus. The placenta may be retained because of the stricture of the 
contracting ring, or because of its size. 

It is not always possible, where the placenta is in the uterus, to 
make a diagnosis of a tear in the cervix which may be causing 
the hemorrhage. If the bleeding comes from a vulvar tear, it is 
possible to see it. It is important, therefore, in cases of doubt, to 
express the placenta as soon as possible. If the uterus contracts 
well after the expulsion of the placenta, the hemorrhage ceases if it 
was from the uterus, if from the torn cervix or vagina, the hemor- 
rhage continues. Examine with two fingers. This is necessary to 
diagnose cervix tears, and then consider the operation, forceps, ver- 
sion, etc., as likely to produce lacerations. Think of rupture of the 
uterus, too. 

After the Expulsion of the Placenta — Here the diagnosis lies 



NOTES ON OBSTETRICS—SENIOR CLASS. 351 

between atony of the uterus and injury to the genital passages. 
Only in extreme cases of atony is the bleeding arterial, almost al- 
ways it is venous; in injuries the hemorrhage is usually arterial. 
You suspect vulvar and vaginal tears in forceps cases. You sus- 
pect cervix tears after breech extraction and version. In general, 
when the uterus is well contracted and there is hemorrhage, it comes 
from some injury. An examination per vaginam settles the point. 

Another point in the diagnosis is, is there a piece of placenta or a 
placenta succenturiata retained in the uterus? Examine the pla- 
centa carefully, and if in doubt, the woman bleeding, examine the 
uterus. Sometimes the uterus relaxes, a clot forms, and then this 
acts like any other foreign body which must either be removed or 
expressed by the fingers. 

Treatment — Prophylaxis. This is important and must begin 
with the first stage of labor. Keep up the woman's strength, by 
giving nourishment and needed rest. Do not empty the uterus too 
rapidly. When the head is born let the uterus expel the rest of the 
child, do not drag the child out of the uterus. Have a hand follow 
down the fundus as the child leaves it. Do not try to hasten the 
third stage by an early Crede expression, and do not manipulate 
the uterus too much, no massage unl-ess the patient bleeds or there 
is internal hemorrhage. After the third stage, in suspected cases, 
give ergot and keep up massage or control for one hour at least. 

(A) Treatment During Third Stage — When the placenta is still 
in the uterus : Massage vigorously, fingers behind, thumb in front. 
After uterus contracts, hemorrhage almost always ceases. Keep the 
hand on the uterus to see that it does not relax and bleed again. 
If the hemorrhage persists you must empty the uterus. Rub it vigor- 
ously and in the moment of contraction squeeze out the placenta, i. 
e., Crede ; repeat the Crede three times, remembering the three 
points: i. uterus contracted; 2. uterus in median line; 3. bladder 
empty. A full bladder can cause retention of the placenta, and also 
post partum hemorrhage. If this is not successful and placenta is 
abnormally adherent, it must be manually removed. In rare cases 
it is not possible with massage to get the uterus to contract suf- 
ficiently to express the placenta when the uterus is relaxed, and, 
further, it is not safe, nor feasible. In these cases a hot vaginal 
douche will usually cause uterine contractions, but if the hemor- 
rhage is severe must go in and remove the placenta by the hand, 
there usually being no time for uncertain methods. 

Manual Removal of the Placenta — Is one of the most dangerous 
operations in obstetrics. The danger of infection is enormous. Over 
25% have severe febrile symptoms (better results now with asep- 
sis, and rubber gloves). 

Chloroform the patient deeply ; now try the Crede again. Very 



352 NOTES ON OBSTETRICS— SENIOR CLASS. 

often it now succeeds, which is fortunate. Careful scrubbing of the 
g-enitaha and vaginal irrigation with hot lysol, i%. 

No case so urgent that the antisepsis can be neglected. Par- 
ticular attention to the finger-nails, singe the hair off the back of the 
hand ; if too long, use alcohol before the bichloride, and, best of all, 
use steriHzed rubber gloves. When everything is ready pass the 
hand along the cord to the placenta. Push' the membranes over the 
fingers between the placenta and the uterus (Hildebrandt), and, 
while the other hand outside steadies the uterus, the fingers, with a 
gentle sawing moven^ent, separate the placenta from the uterine wall. 
It is generally very easy, but in rare cases the adhesions are firm 
and have to be cut with the finger-nails. The uterus contracts 
well down on the hand and after the placenta is separated usually 
expels both the hand and placenta. If the contraction ring is tight, 
gentle pressure, chloroform and waiting a little will almost always 
overcome the resistance. Under no circumstances use force. After 
removing the placenta, go through the lysol again and make a care- 
ful revision of the uterine cavity to see if there is not a piece still 
left. If using rubber gloves, wrap a piece of gauze around the 
tw^o middle fingers, using this to wipe the uterus smooth. After 
this, a hot uterine lysol douche ( i % ) , allowed to flow for two min- 
utes. Give ergot. Do not give ergot as long as placenta is in utero. 

Rare cases where a sudden enormous hemorrhage follows the 
delivery of the child, compress the aorta, grasp uterus from within 
and without. 

Treatment After Expulsion of the Placenta — In all cases make a 
careful examination of the placenta. If a piece larger than an Eng- 
lish walnut is missing, go into the uterus for it (with the pre- 
cautions already mentioned), and do this always, if the patient bleeds. 
If smaller than this size, leave it alone; massage, ergot, wait. It 
will usually be expelled in the first days of the puerperium, but 
they sometimes become infected. If the hemorrhage is from a cervi- 
cal tear, sew up the rent, or pack the utero-vaginal tract full of 
gauze. 

(i) In all cases massage the uterus briskly. Knead it well, and 
usually one succeeds in stopping the hemorrhage by this simple 
means. If the uterus is full of clots, squeeze them out, but not too 
often. 

(2) Give ergot, i drachm by mouth, minims 25, hypodermically. 
Squibbs fluid extract, or Sh. and D. ergotole, or ergot, aseptic, P. 
D. & Co.'s. But do not wait for the ergot. Get contraction and 
retraction yourself. Do not rely on ergot to do it, you may be 
disappointed. Proceed as if none had been given. Lam of Pajot — 
"Never give ergot when there is anything in the uterus.'' 

(3) Give the patient a hot uterine antiseptic douche, tempera- 



NOTES ON OBSTETRICS—SENIOR CLASS. 858 

ture 1 20 degrees Fahrenheit, or as hot as she can stand it. It is 
not advisable to use cold water, or ether, poured on the abdomen, 
nor is it advised to slap the abdomen with a wet, cold, towel, i 
think these are all too depressing, especially when the patient has 
lost a great deal of blood. Heat is needed. 

(4) Old and tried method: Squeeze a large pledget of cotton, 
soaked in vinegar, in the uterus. Mode of action is by irritation 
of the endometrium, and this is needed when the patients are anemic. 
Do not use the Tr. Ferri Chloridi for this purpose, because it makes 
a thick layer of coagulated fibrin, which is so much dead matter 
and predisposes to sepsis ; further, the thrombi may extend through 
the uterine wall and give rise to emboU. Not necessary and bad. 

(5) Compress the uterus in anteflexion. Breisky's method. 
Good to gain time, may keep it up for ten minutes, till hot douche 
is ready or ergot has begun to act. 

(6) Massage uterus outside and inside. 

(7) If the hemorrhage still persists, compress the abdominal 
aorta, — Nos. 5 and 7 may also be used in these severe cases, where 
the hemorrhage comes wnth a gush, and something must be done in- 
stanter, or the patient is lost. 

(8) Tampon the uterus with lysol gauze. It takes 10 or 12 
yards, one-half yard wide. Tampon tightly the w^hole parturient 
canal. Leroux used medicated tampons in the uterus for post partum 
hemorrhage, in 1776, but Diihrssen brought the scientific uterine 
tamponade to the notice of the profession in 1887. 

During this time, or immediately after you have gotten the hemor- 
rhage under control, you will have to direct your attention to the 
treatment of the more or less profound anemia. The symptoms of 
anemia have already been given. In treating the anemia there are 
several conditions to be fulfilled. 

(a) Remove the cause of the anemia, i. e., stop the hemorrhage. 

(b) Keep up the body heat. Do not allow the patient to get 
cold. In the hurry that almost always attends these cases, this 
point is likely to be forgotten. Patient should be well covered up 
and hot water bottles be applied to the feet, sides and arms. See 
that they do not burn the patient. 

(c) Keep up the heart's action and supply the brain with blood. 
Death is usually due to cerebral anemia from the empty cerebral 
vessels. The blood vessels, especially those going to the brain, must 
be kept full, (i) Stimulants, hot coffee, wine or whiskey. For 
more rapid action give strychnia, gr. 1/30, repeat in one hour. 
Camphorated oil, one hypo, barrel full, repeat every twenty minutes 
until three barrels. Ether' in the same way and dose, deeply in the 
thigh ; these two have a powerful stimulating effect. Also, aromatic 
spirits of ammonia. 



354 NOTES ON OBSTETRICS—SENIOR CLASS. 

Now to supply the brain with blood. Elevate the feet, let the 
head hang low, perhaps necessary to elevate the foot of the bed, 
which should be raised three feet. Auto-infusion, i. e., circular 
bandaging of the legs and arms, not of much value and risky. 

(d) It is possible to increase the total quantity of blood in a 
short time by means of free exhibition of fluids, ist. By mouth, 
but careful not to cause vomiting, which, especially in anemia, is 
likely to occur and be a very annoying symptom. Sometimes pa- 
tient feels better after vomiting. 2nd. By rectal injections. Normal 
saline solution, warm. Not advisable to use whiskey and coffee, as 
they usually come out and then the rectum is intolerant of anything 
else. After the salt solution is in, compress the anus for ten min- 
utes. 3rd. The direct transfusion of blood is no longer practiced, 
but a solution of salt, .7 of i per cent., is frequently used, either di- 
rectly into the veins or under the skin. Sterile salt, sterile water. 
Needle under skin of breast. Lift the bag up four feet or higher ; 
solution forms a tumor. Now push the needle in another direction. 
May put in twelve ounces to two pints in each side. Cover with ad- 
hesive plaster. In fifteen minutes ©ver one-half is absorbed, in three 
hours nothing is left. Very good method in that it can be used 
before undertaking an operation that will necessarily cause the loss 
of some blood. In desperate cases, where great haste is necessary, 
put the solution directly into the median basilic vein. 

ECLAMPSIA. 

A woman during labor can have convulsions, due to epilepsy, 
hysteria, meningitis, tumor, apoplexy, acute anemia. Epilepsy is not 
common, pregnancy seeming to exert a favorable influence on the 
disease. An epilepsy of pregnancy has been described. Said that 
there exists a relation between eclampsia and epilepsy. Fere says 
they are similar, and cases are on record where eclampsia was fol- 
lowed by real epilepsy. 

Hysteria is also quite rare during pregnancy, but there is great 
likelihood that the attacks will become worse after labor. The 
other accidents are quite rare, but this does not throw them out of 
consideration. 

A woman that has convulsions in the latter part of pregnaoicy or 
labor or puerperium, in ninety-nine cases out of a hundred, has 
eclampsia. The convulsion resembles an epileptic convulsion, but 
recurs very soon. The stupor after each convulsion becomes longer 
as the number of attacks increases, till there is more or less deep 
coma between the attacks. This is the usual picture of eclampsia 
and there is almost always no difficulty about the diagnosis, but this 
should not make one careless. 



NOTES ON OBSTETRICS—SENIOR CLASS. 355 

Eclampsia means "to burst out," to "shine out," and refers to 
the fact that the disease suddenly appears in all its violence, without 
warning. Close observ^ation of pregnancy cases will usually discover 
sufficient warning. 

Causatioji — The disease, in round numbers, occurs i :5oo cases, 
but this varies much. Seen much more frequently in primiparae than 
in multiparae. It occurs most often during labor itself, then dur- 
ing puerperium, and least often in pregnancy. Occurs in last three 
months, but cases (fatal, too) are on record of eclampsia in the 
3rd, 4th and 5th months. Schroeder, 316 cases, 190 cases in labor, 
64 cases in the puerperium, 62 cases in pregnancy. Twin pregnancy 
gives a special disposition to eclampsia. It is also more frequent in 
cases of contracted pelvis. The cases are more frequent in damp, 
cold w^eather ; therefore, in the fall or in March. Heredity is said to 
have some influence. Elliott reports a case where the mother and 
four daughters died of eclampsia. The real cause of the disease is 
still unknown. Until very recently the theory that it was due to an 
inflammation of the kidneys, and, therefore, uremia, was very gen- 
erally accepted. Now there is doubt about this. In 1867 Carl Braun 
claimed that every case of eclampsia was due to acute renal insuf- 
ficiency, and that this was the result of some organic or functional 
disease of the kidney. There is a great deal of evidence in favor of 
this view, so that it has kept its place till recently. The occurrence 
of albuminuria, casts, renal epithelium, pointed to nephritis. Still, 
Ingerslev reports 106 cases of eclampsia where no albumen or casts 
were in the urine, and where post-mortem no pathological changes 
in the kidney were present. Value of these observations is doubtful. 
Other theories are that of Halbertsma, compression of the ureters; 
that of Traube, anemia and hydremia cause edema of the brain. 
That it is due to ammonium carbonate in the 'blood; acetonem^i ; 
carbamic acid. 

In eclampsia there is high arterial tension, shown by the pulse 
and the sphygmomanometer. This high arterial tension is due to 
increase of the amount of the blood and spasm of the vaso-con- 
strictors.. There is a great increase in the amount of fibrin in the 
blood, which explains some of the difficulties of venesection. In- 
fant has same condition. The urine (contrary to Bouchard) has 
been found equally toxic to animals, in the pregnant, non-pregnant 
and eclamptic conditions when of the same specific gravity. The 
blood serum is the same for all. 

Veit's theory^, — deportation and solution of syncitium, and lack 
of anti-bodies. 

Generally Accepted Theory of Eclampsia — The theory that is 
generally accepted now is that the eclampsia is a symptom of some 
sort of poisoning of the blood, — a toxemia, — there are present in the 



856 NOTES ON OBSTETRICS—SENIOR CLASS. 

blood, organic poisons, either results of bacterial activity or the re- 
sult of some anomaly in the metabolism of the mother or of the 
fetus. What these poisons are has not been settled. By some it is 
claimed that the poison is a toxine absorbed from the intestinal tract. 
Others, that it is a toxine, the result of germ growth in the blood, 
claiming to have found a characteristic microbe, i. e., that eclampsia 
is an infection. Others, that the poison comes from the mother her- 
self. xA.gain, from the fetus, and especially the placenta. ( See chap- 
ter. Toxemia.) In support of the last vievy, are the facts, that the 
eclampsia generally ceases when the ovum is removed, also when 
fhe fetus dies ; further, that the tendenc}- to eclampsia increases 
as the fetus grows larger. The theory of poisons circulating in the 
blood is supported by many points : ( i ) The pathological condi- 
tions found post-mortem, — cloudy swellings, changes in the kidneys, 
and especially the liver. (2) The toxicity of the urine decreases 
during the attacks, while that of the blood is much increased 
(Bouchard). The attacks are, therefore, due to an acute increase 
in the amount of the poisons. (3) The symptoms are those of an 
intoxication, gastric, cerebral symptoms, sudden onset, and the fre- 
quency of nervous disorders following, — amaurosis, anomalies of 
hearing and taste, which are analogous to the neuroses after typhoid 
and diphtheria. Still, while accepting this theory, we must recog- 
nize its incompleteness and take Shroeder's advice, not to consider 
anything as definite but to be ready to accept the truth when it be- 
comes known. The frequency of eclampsia in cases of nephritis is 
due to the impairment of the eliminatory function of the kidneys. 
In those cases where eclampsia occurs after a long, hard labor, it 
may be due to the accumulation of poisons, the result of great muscu- 
lar effort. 

Cause of Convulsion — What is the cause of the convulsion? Sev- 
eral adjuvant factors eHcit the convulsion. A rough palpation, 
a jar to the bed, a hypodermatic injection, an enema, an examina- 
tion or operation, pressure of the head on perineum, a bright light, 
loud talking. The real cause of the convulsion is generally sup- 
posed to be a spasm of the vessels of the brain analogous to that of 
epilepsy. There is some difference of opinion on this point, but the 
theory has much in its favor : ( i ) The rapidity of its occurrence 
and disappearance. (2) The absence of findings post-mortem in 
the brain. (3) The good effects of vaso-dilator treatment. (4) 
Experimentally, acute cerebral anemia will cause convulsions. 

During pregnancy there is a gradual increase in the excitability 
of the nervous system, like children. There is an accumulation of 
excrementitious matters in the blood. These poisons irritate the 
vaso-motor centers, or the vessel centers and motor centers at the 
same time. If the vessels of the cerebral hemispheres are involved 



NOTES ON OBSTETRICS—SENIOR CLASS. 35V 

we get coma, if the pons and medulla, convulsions. The convulsions, 
then, given the increased irritability due to pregnancy- and the added 
poison, can be easily elicited by one of the external irritants men- 
tioned. 

Thus defined, we may say that in all probability eclampsia is due 
to poisoning of the blood from unknown source, which, owing to a 
hyperexcitability of the nervous system and some impairment of 
the function of the liver (as an elaborator of poisons), or of the 
kidneys (as eliminators of poisons), causes a spasm of the blood 
vessels of the brain by acting on the vaso-motor centers. 

Pathological Anatomy — Changes are not so marked as one would 
expect in such a severe disease. 

In the liver, there are usually small or large hemorrhages, not 
so much through the substance as under the capsule in the neighbor- 
hood of the suspensory ligament. The hemorrhages in the liver 
substance are not simple, but are due to necrosis, with typical loca- 
tion around the branches of the portal vein. Focal necroses. The 
condition is called acute- peri-hepatitis hemorrhagica. The liver it- 
self is yellowish mottled, shows a fatt}' degeneration and anemic ne- 
crosis, especially around the periphery of the lobules. The process 
may be so advanced as to resemble a case of acute yellow atrophy of 
the liver. 

The kidneys almost always present some signs of disturbance. 
In 289 cases observed, from 1892 to 1900, in the Berlin Charite, 
there were symptoms referable to the kidneys in all, and these 
changes were found in all that went to autopsy. Schmorl (C. f. G.. 
1901), in 73 cases, found one with normal kidneys. A very severe 
congestion in some cases, often the signs of a more or less acute 
nephritis. Cloudy swellings, and fatty degeneration of the epi- 
thelium. Thrombosis of the glomeruli and smaller veins and arteries 
(Schmorl). Or the kidney of pregnancy, with an acute inflamma- 
tion. This is hard to distinguish from acute parenchymatous nephri- 
tis. Further, we find in all forms of chronic Bright's disease. 

Lungs — Almost always congestion and edema, very often hemor- 
rhages, which are usually under the pleurae. Broncho-pneumonia is 
not rarely found, due to admission of food particles, blood, slime, 
etc., into the air passages. Gangrene of the lung, sometimes, is the 
cause of death. Small arterial and venous thrombosis. Emboli of 
liver cells, of decidual cells, and cells that look like hypertrophied 
nuclei of lymphoid cells of the bone marrow, syncitium. These 
are not characteristic, occurring in other conditions. 

Heart — Usually contracted, auricles full of a dark, purplish blood 
which does not clot readily. Heart muscle fatty, tears easily. This 
is a fatty degeneration of the heart, which is often the cause of death. 
Said (and quite plausibly) that the continued administration of 



358 NOTES ON OBSTETRICS—SENIOR CLASS. 

chloroform predisposes to fatty heart. There may be sub-pericardial 
hemorrhages. The amount of fibrin in the blood is much increased. 
The blood is thickened. 

Brain — The changes found here are the least marked. Flat- 
tening and moderate edema of the convolutions, sometimes a little 
increase in the cerebro-spinal fluid. Rarely a severe congestion, 
more often the signs of anemia-cerebri. Sometimes there are hemor- 
rhags, which may be small or large, and may occur in the ventricles. 
The infrequency of hemorrhage has been emphasized, but Zweifel, of 
Leipsic, says apoplexy is common, and that, ''All theory notwith- 
standing, these show that there is great cerebral congestion, so great 
that even the elastic arteries of young people are ruptured." 
Schmorl, 1. c, says, in 65 autopsies, he found 58 cases of hemor- 
rhage, either small ones or large, or areas of cerebral softening, often 
together with thrombosis. In unusual cases other causes of the con- 
vulsions can be found in the brain, e. g., tubercle, tumor, etc. These 
changes are occasionally found also in the children of eclamptic 
mothers (Bar). 

Clinical Course — The eclamptic attack may occur suddenly with- 
out warning, but often there are premonitory symptoms. If the case 
was one of albuminuria during pregnancy, of course you will be on 
the look-out for symptoms, and if at all careful will not be caught 
unawares. 

Premonitovy Symptoms — These are headache, nausea, vomiting, 
disturbances of vision (often due to a retinitis gravidarum), twitch- 
ings in the muscles of the calf, of the hands, dizziness, stomach 
ache. The patient may complain of other disturbances of the spe- 
cial senses, of spots before the eyes, ringing in the ears, even deaf- 
ness ; disturbances of taste and smell. These are present i to 24 
hours before the outbreak and serve to draw attention to the condi- 
tion of the patient. These warnings should be heeded. Rarely, the 
convulsions come on suddenly. Wherever the patient may be she 
falls to the ground unconscious. The pupils dilate, the eyes are 
turned, the head also, to one side ; the patient opens her mouth, then 
the jaw is pulled to one side. There may be a cry or a sigh. The 
whole body becomes rigid. The features are horribly distorted, the 
arms flexed, hands clinched, the feet inverted, the toes flexed. The 
patient may be drawn slightly to one side. This condition lasts for a 
few seconds, then the jaws open and close violently, the eyelids 
also, spasm begins in the face, then usually one arm, then the head, 
and now the whole body. This is a violent clonic convulsion, which 
may throw the patient out of the bed against any object. Severe 
injuries can result, as fractures; the tongue is protruded, the teeth 
may chop it up. Foam comes from the mouth, often tinged with 
blood. The respiration is completely stopped, the chest being rigid. 



NOTES ON OBSTETRICS—SENIOR CLASS. ;?59 

The pnlse is high and strong, later it grows weaker, but is some- 
times hard to feel because of the convulsion. The eyes are wide 
open, the face is swollen, the picture is horrible. The cyanosis is 
extreme, the lips are purple. The convulsive movements remit, a 
few twitches or jerks take place, the patient lies quiet, the heart 
thumps violently against the chest wall. A few seconds the patient 
appears to be dying, there is a long sigh, and the respiration becomes 
stertorous. Gradually the respirations quiet down and the woman 
lies in coma. In the favorable cases she wakes up after a short 
time, bewildered, severely sore in the muscles. After a few min- 
utes to an hour, another fit occurs, or she may have no more. With 
the recurring convulsions, intervals become shorter, the patient lies 
in deep coma all the time. Fever now begins, the pulse goes "up. 
The fits may occur every five minutes, but visually the time is 
twenty minutes. They may show some regularity of recurrence. 
She may have as many as 60 a day. Cases are on record of 80 and 
90 convulsions. These cases almost invariably die. Labor usually 
begins if the convulsions are at all severe, and labor is usually rapid 
if the pains liave once begun. The convulsion lasts from ,30 seconds 
to two minutes, very rarely any longer, and these are bad cases. 
After labor the convulsions usually cease or become infrequent. The 
patient lies in coma from six hours to a week (rare), finally awakes 
with no recollection at all of what has happened ; may even be sur- 
prised and deny her own child, when it is presented to her. 

When the case takes a fatal course the attacks increase in imm- 
ber and become more violent. The temperature goes up, usually to 
103, sometimes to 105, or down ; the pulse goes up, becomes weak 
and running. Signs of edema of the lungs appear, rattling, cyanosis, 
even between the convulsions, or death may take place at the height 
of a convulsion from apoplexy or heart paralysis. 

Sometimes the w^oman is successfully delivered, but the pulse does 
not improve, the coma deepens, and edema pulmonum carries oflf the 
patient. Some cases are bad from the start. The patient may die 
after one or two convulsions in a few hours. Further, some cases 
have convulsions for one or two days, and then recover. Sometimes 
there are no fits, patient falls at once into coma. As a rule, the case 
ends one way or the other inside of three days. Examination of the 
urine shows it very albuminus and full of casts. 

Prognosis — Always very guarded ; even in the apparently lighter 
cases, death sometimes takes place. Hemorrhages into the brain, 
edema pulmonum, edema laryngis, and asphyxia, during the attack. 
Exhaustion, heart failure, embolism, thrombosis of pulmonary- 
artery, toxemia. Later,- she may die of sepsis, which is quite com- 
mon after eclampsia. Sometimes the severer cases recover, so assert 
neither way, but explain the gravity of the case and have counsel 



360 NOTJiS ON OBSTETRICS—SENIOR CLASS. 

always. Fiirtker, the patient is endangered by the severe operations 
which are necessary to dehver her. Tears of the cervix have not 
seldom been the cause of death by anemia or sepsis. The per cent, 
of deaths is about 25. This has not been influenced as much by the 
treatment in the last few years as one would like. Different authors 
oive from 7% to 35%. But the cases vary so much that unless more 
than 100 are used as a basis, conclusions as to this or that method 
of treatment are absolutely of no good. 

For the child, the prognosis is bad. Over 50% die, either dur- 
ing the labor, or in the first few days after it. The baby dies of 
asphyxia, or of the same poison from which the mother is suffering ; 
it may even have eclampsia if born alive. May die of morphine 
poisoning. In some cases cranioclasis is performed in order to de- 
liver rapidly. 

Diagnosis — This is usually not difficult. The severity of the case 
is usually sufficient. When you are not present during the con- 
vulsion, but find the patient in more or less deep coma, the descrip- 
tion given by a neighbor is useful. The attack resembles in all re- 
spects an epileptic convulsion, but is distinguished from this by the 
repetition and the prolonged coma. From apoplexy .by the same 
sign and a prolonged local paralysis. This is absent in eclampsia, 
unless complicated by hemorrhage. 

It is impossible to distinguish repeated fits due to brain tumor. 
Treat the case as eclampsia. Hysteria will never give any trouble. 
The evident intention in the movements, the fact that the patient 
does not hurt herself ; the ludicrous positions assumed, which are 
plainly hysterical, and the absence of a type of the movements, i. e., 
tonic and clonic, serve to make a diagnosis plain. 

Consciousness is not lost. Further, there is no albuminuria, 
there is no fever, there is no rapid pulse. The history of the patient, 
her character. Then there are often hysterical paralyses, anesthesia, 
which may be general, restriction of the visual field. 

Important is the diagnosis of the severity of the case. Here the 
pulse gives the most important information. If the pulse remains 
full, hard, below 120, there is no immediate danger. If above 120, 
soft, weak, compressible, or even running, the prognosis is very 
bad, almost always there is a fatal termination. 

High fever is not as bad a symptom as a very subnormal tem- 
perature. Above 103.5 is bad. Symptoms of edema of the lungs, 
e. g., bloody froth from the mouth and nose, rattling in the chest, 
are bad. Cyanosis between the attacks ; many severe and long con- 
vulsions are bad ; if the convulsions persist after the uterus is emptied, 
bad ; but if milder than before, and the pulse is good, not a fatal 
sign. 

Treatment — Prophylaxis is of great importance. Careful exam- 



NOTES ON OBSTETRICS—SENIOR CLASS. ?Ql 

ination of the urine in every case of pregnancy, at least every three 
weeks, preferably every week and, in suspicions cases,, every day. A 
general examination of the patient is also desirable, to see if there 
is any change in the heart, liver, etc. A careful watchfulness for 
symptoms of toxemia is just as important. Treatment of albuminuria 
during pregnancy must always be instituted, even though all cases 
of albuminuria do not develop eclampsia. A carefully observed milk 
diet. Systematic employment of the hot bath. Careful attention 
to the bowels ; in short, the tre^rtment prescribed for nephritis during 
pregnancy. If after ten days the edema increases or does not im- 
prove, the headache, nausea and vomiting, disturbances of sight, etc., 
arise betokening involvement of the brain, it is justifiable to terminate 
the pregnancy. 

Labor Induced Tims — Chloroform. Preparation of the patient. 
Dilate cervix, if not already dilated, to admit Barnes' bag. Punc- 
ture bag of waters, insert bag, fill it and put patient to bed. Give 
two pints of saline solution hypodermically, if the patient takes no 
fluids. If tendency to convulsions give chloral. As soon as delivery 
possible, forceps if necessary. See- that the uterus is empty, that no 
clots form in its cavity. These cause after-pains, which may tend 
to prolong the convulsive state. 

After delivery — O iv Saline Sol. in the colon, epsom salts by 
mouth, also chloral gr. xxv; and gr. ^ morphine hypodermically. 
These should be given before patient awakes from the anesthetic. 
Catheterize also. After this not to be disturbed. 

Any operation undertaken zvhile eclampsia is threatening must 
be done in anesthesia. After an attack has occurred, the case re- 
quires the constant attendance of the physician. 

AFTER THE CONVULSIONS HAVE OCCURRED. 

After the Convulsions Have Occurred — 

(i) Put her to bed with numerous pillows to protect her from 
the vehemence of the attack, which sometimes becomes frightful. 
Wrap a clothes-pin in a thin handkerchief and place it between the 
teeth (hang it over the bed w^hen not in use). Keep the room dark- 
ened, head against the light and patient should be lightly covered. 
No visitors, no loud talking. Bladder empty. Do not disturb the 
patient except for treatment. 

(2) Narcotize the Woman. As a rule, do not use chloroform ; 
only where the convulsions have been recurring too rapidly, e. g., 
every five minutes, or where there is extreme jactitation. May 
be used but not kept up for hours, as is sometimes done. It is a 
cause of fatty degeneration of the heart muscle, and some of the 
deaths must be ascribed to the chloroform, not to the eclampsia. 



362 NOTES ON OBSTETRICS—SENIOR CLASS. 

Give the patient % gr. of morphine hypodermically, repeat in 30 
minutes, if there is another convulsion. Do this even if^the patient 
is comatose. Repeat again in 30 minutes if there is another fit, or if 
the patient is restless. Give 45 grains of chloral per rectum in milk. 
Repeat this in two hours. 

Now what to do ? If the patient has labor pains, rupture the bag 
of waters. If labor has not begun, the question is hard to decide. 
Majority of authors are opposed to the induction of labor (prema- 
ture) when the eclampsia occurs during pregnancy. All advise in- 
duction of premature labor when the eclampsia is threatening ; there- 
fore, why not when it has broken out? Still, the question is almost 
always settled by nature herself, for very soon after the beginning 
of the convulsions labor pains begin and labor is soon terminated. 
Watch the uterus carefully, and if you see that there are pains, rup- 
ture the bag of waters. If the attacks continue in spite of narcotics, 
must also terminate pregnancy. 

The question of bleeding has been discussed very much. Former- 
ly the custom was to bleed, in every case. Soon after chloroform was 
used in obstetrics, it supplanted bleeding almost entirely. In fact, 
bleeding was called a barbarous, ancient and useless procedure. It 
had its advocates, however, in the country practitioner. Now one 
voice after another is being raised in behalf of venesection, and it 
bids fair to occupy an honored place in the treatment of eclampsia 
again. It is very advantageously combined with the infusion of 
saline solution — so-called washing the blood — recommended by the 
writer in 1895. 

Indications for Bleeding — 

(i) Signs of pulm.onary edema, cyanosis, rattling in the lungs, 
bloody foam in the throat. 

(2) Repeated convulsions which seem not to be affected by the 
narcotics. 

(3) Great cyanosis, together with severity of the convulsions. 
In full-blooded patients with a high, full pulse, bleeding does good. 
But if the pulse is small and running, no one advises bleeding. In- 
deed, these cases very rarely recover under any treatment. 

(3) Obstetrical Treatment — The majority of cases of eclampsia 
recover when the uterus is emptied. Still not all, and eclampsia 
occurs even during the puerperium. Why this is has not been set- 
tled. Some say that the removal of the child removes a source of the 
poisons which cause eclampsia. It is said that after the child dies 
eclampsia ceases. True in a certain number of cases, but eclampsia 
has occurred when the fetus was dead and macerated. Others say 
that the fetus forms an irritant and when this is removed, the con- 
vulsions cease. Third theory is, that the removal of the ovum re- 
lieves the pressure on the kidneys, etc. Diihrssen advises imme- 



NOTES ON OBSTETRICS—SENIOR CLASS. 363 

diate delivery in all cases, incisino; the cervix, the vagina and peri- 
neum, if necessary. The majority of authors condemn this, but a 
very large number concur in hastening the delivery as much as pos- 
sible, — as much as is consistent with the safety of the mother. 

Early in the first stage, puncture the bag of waters. In about 
one-third of the cases convulsions will cease or be very much less 
severe, and infrequent. Usually labor progresses very rapidly. Pains 
strong and often. If the convulsions are frequent and the coma deep 
and labor progresses slowly, under anesthetic (chloroform), dilate 
the cervix with the fingers (Barnes' bags, if it is not yet effaced), 
and deliver the head with forceps. If the child is dead, as is not 
seldom the case, use the cranioclast. Vaginal Caesarean Section is 
proposed. All operations in anesthesia. Bossi's dilator is danger- 
ous. Caesarean Section has also been suggested. 

It is seldom necessary to make cervical incisions in order to 
hasten delivery. In the severe cases, where the convulsions are fre- 
quent, the coma profound, and the pulse going up, these may be 
necessary. Let the woman bleed freely, but be certain that no 
clots are left in the uterus. This may be accomplished by tampon- 
ing the uterus, and removing the gauze after one or two hours. 

(4) Elimination — Aid in the elimination of excrementitious mat- 
ters, or poisons, from the blood. Bleeding, to a certain extent, ac- 
complishes this. The methods to be given here are more applicable 
to cases occurring during pregnancy and in the puerperium. 

(a) By the skin. Hot water packs : Not the baths, because 

it involves too much disturbing the patient. If there 
are fits the baths are very troublesome. 

(b) By the bowels : Not useful during the labor. Do not 

use croton oil if avoidable, but give two ounces of 
castor oil by the rectum. Later, free exhibition of 
salts. Not rarely the cathartics will not act. The 
bowel seems paretic. Tympany develops. As early 
as possible in a case give a large dose of salts, with a 
vegetable cathartic, as jalap. This before she has got- 
ten comatose. 

(c) Diuretics of little value, still certain authors are much 

pleased with the free administration of lemonade, with 
the stomach tube if the patient is soporose. A method 
that recently came into vogue is sub-dermal or intra- 
venous injection of saline solution. Dilutes the blood, 
•favors diuresis and diaphoresis. Combined with vene- 
section is good, and salt solution should be injected 
into the bowel. 
In the puerperium, same treatment, but, of course, no obstetric 
narcosis. Eliminatives, liquid diet, especially if disease prolonged. 



364 NOTES ON OBSTETRICS—SENIOR CLASS. 

There are several other methods of treatment, of which the use 
of veratrum viride is first. This is called the American remedy, 
and is useful as an adjuvant, but is not to be relied upon alone. Given 
in 5 drops to the dose hypodermically of Norwood's tincture, every 
30 minutes, till the pulse is brought to 60 beats per minute, it is said 
to control the convulsions. My own experience is negative. 

Oxygen is useful to combat cyanosis and to support the heart 
while the patient is in the profound coma that follows the attack. 
It also lessens the danger of edema pulmonum. 

Regarding laceration of the perineum. If operative delivery, 
repair perineum. If no operation, but convulsions after delivery, 
wait for two weeks. Condition of patient to guide. 

The patient may need stimulation, and then camphorated oil, 
aromatic spirits of ammonia and, rarely, ether may be used. 

The cases should be watched carefully and constantly, not being 
left alone an instant, and the indications for treatment promptly 
followed. These may vary every hour, and, therefore, the accoucheur 
must stay at the bedside till all danger is past. Success in the treat- 
ment of these formidable accidents depends on interpreting the con- 
ditions of the cases. 

RUPTURA UTERI. 

This serious accident occurs i :2,ooo cases. Not possible to get 
statistics because a large number of cases are not diagnosed. From 
the number found at post-mortem, one is led to believe there are more 
than are recognized. To understand how it occurs we must refer to 
the normal mechanism of labor. 

Dilatation of the low^er uterine segment and cervix, fibres drawn 
up into the body of the uterus. Now external os dilates. Fundus re- 
tracts over the child, the lower uterine segment and vagina form 
one long, thin, continuous tube. Too great retraction of the fundus 
over the child is prevented by the round ligaments which anchor the 
uterus to the pelvis and by the tension of the abdominal walls. Thus 
the uterus is pressed down with the child, the latter is forced into the 
pelvis. Should the presenting part not get into the pelvis, because 
of contraction of the inlet, and the pains be strong, the uterus will 
draw up higher, the lower uterine segment and cervix will get 
thinner, till finally the whole child will lie in the lower uterine seg- 
ment and the stretched vagina. The round ligaments, under these 
circumstances, are excessively tense and painful and insert high up 
on the uterine body. The thickness of the lower uterine segment 
now may be that of blotting paper, the fibres are separated, and a 
rupture is imminent. The same conditions occur when the shoulder 
presents and the condition is called ''Neglected transverse presenta- 
tion." 



NOTES ON OBSTETRICS—SENIOR CLASS. 365 

The individual tendency to rupture, or rather to this dangerous 
thinning of the cervix and lower uterine segment, varies much, but 
as a general rule multiparae are more subject than primiparae. Old 
patients more commonly than younger ones. Women w^ith loose ab- 
dominal walls more than those with tight walls. Fat women more 
often than thin women. If this state is not quickly relieved the 
thinnest spot may give way and all or part of the child escape into the 
abdominal cavity. This usually occurs at the height of a pain but may 
occur when the patient turns in bed, or coughs, or by some rough 
palpation of the lower abdomen, pre-eminently, by some attempt at 
internal version. The part that gives way is that part w^hich suffered 
the greatest dilatation. In cephalic presentations that side on which 
the occiput lies. 

The rupture may be incomplete, when the fibres of the uterus tear, 
but not the peritoneum ; or complete when everything tears into the 
peritoneal cavity. Important difference. 

Causes. 

A. x\ll mechanical factors that can prevent the engagement or 
further progress of the child can cause uterine rupture ; such are : 

(i) Contracted pelvis, or any obstruction, e. g., exostoses. 

(2) Transverse presentation — common cause.^ Pelvis normal 

or pathological. 

(3) jXIalpositions of the head, e. g., Mento-posterior positions. 

Anterior and posterior parietal bone positions, etc. 

(4) Hydrocephalus. 

(5) Obstructions of the soft parts, e. g., atresia of the cervix 

or vagina, tumor, etc. 

B. Rupture sometimes the result of operative procedures — for- 
ceps, version, craniotomy, etc. 

C. Causes which produce a Aveakening of the uterine wall, e. g., 
syphilis, tuberculosis, fatty degeneration, sepsis, previous rupture of 
scar of Caesarean section, pressure necrosis. 

The tear is almost always in the lower uterine segment. It is 
usually oblique, but may be parallel with the long axis of the uterus, 
in which case it may extend above the contraction ring toward the 
fundus. Or the uterus may tear off at its vaginal attachment. The 
tear has jagged and- bruised edges v/hich are thin. The tear may be 
anterior or posterior or at the side, depending where the greatest 
stretching was. It may open the bladder, the broad ligaments. A 
large hematoma may form under the peritoneum, which later may 
rupture into the peritoneal cavity, or burrow up under the kidneys 
or elsewhere. Amount^of bleeding varies. Rupture almost always 
takes place long after the bag of waters have ruptured, but some- 



36(3 NOTES ON OBSTETRICS—SENIOR CLASS. 

times (rare) it occurs before. Rupture may take place at the begin- 
ning- of labor, again it occurs only after long and hard labor. 

S^ymptoins — The beginning of dangerous stretching of the lower 
uterine segment can almost always be determined if the accoucheur 
is on the alert. The probabiHties that it will occur in a given case 
will aid in the diagnosis. Given a case where you know that there 
is some obstruction to the advance of the child, you must look out 
for rupture of the uterus. Still only too often the condition is diag- 
nosed after rupture, or when peritonitis has developed, or at the post 
mortem. 

The patient is restless, anxious, from long labor, complains of pain 
all the time, has no rest between pains but moans continually. At 
the height of a pain or when the patient changes her position she 
experiences a sudden tearing in the abdomen ; she says something 
has burst inside her. Still again the tear may be slow and gradual 
and the condition may be recognized after the symptoms of shock 
have developed. After this the aspect of the case changes. The 
pains immediately cease or become w^eak, and some hemorrhage 
appears. These are two important signs. The point of rupture be- 
comes more tender, now symptoms of collapse appear, fast, quick, 
small pulse, pale, cold sweat, fainting, impressions of impending dis- 
solution, dyspnea. Or the symptoms may be those of internal hem- 
orrhage, in which they take several hours to develop and are similar 
to those from rupture of an extra-uterine pregnancy ; or the symptoms 
may be slight and later a septic peritonitis developing, or the patient 
discharges peritoneal fluid, the diagnosis is made. Fortunately these 
sub-acute cases are rare. 

Signs — 

L Threatened Rupture. 

a. Notice restless, anxious patient ; face pale, rapid, high pulse ; 

may be a little temperature. 

b. Strong pains and no advancement of presenting part. 

c. Uterus hard and drawn up over the child, which lies in 

the dilated lower uterine segment. Fundus hard, lower 
uterine segment soft and balloons out during a pain. 
Can see the contraction ring which usually runs from 
the right above, left below. Differentiate the bladder 
and gas, which is rare — catheter, percussion. 

d. Round ligaments tight, hard, wiry and very tender, espe- 

cially on the side which the rupture threatens. They 
insert high on the uterus. 

e. General tenderness over the uterus, but especially over the 

lower uterine segment. 
TL Actual Rupture. 

a. Notice collapsed patient. Notice none or weak pains. 



NOTES ON OBSTETRICS—SENIOR CLASS. 367 

b. Hemorrhage externally — mild, severe, rarely none. 

c. Cannot feel presenting part through vagina. It has gone 

or it has become freely movable. 

d. May feel the tear, or feel intestines which have prolapsed 

through the rent. 

e. If the child is in the abdominal cavity, feel a small hard 

lump which is the uterus, one one side, and the child on 
the other, or if partly extruded, feel two tumors. 

f. When the tear is sub-peritoneal may feel emphysema. If 

there is decomposition, always fatal. 

Diag}iosis — Generally not difficult, when possibility of a tear is 
recognized and the above symptoms are considered. Attention to 
the previous symptoms settles diagnosis. 

Prognosis — Very grave. Formerly w^as 95% for mother and 99% 
for child. Dangers are sepsis and hemorrhage — external, internal. 
Better now^ since antisepsis is practiced. Article by Cholmogaroff 
gives the mortality running from 21^% to 65%, depending on no 
particular line of treatment. Since the fetal mortality is nearly 100% 
we pay no attention to the child, but do everything to save the 
mother. 

Treatment — Of course prevention pla}s the most important role. 
Watch your cases carefully, if there is no progress in the labor in 
spite of good pains. If you diagnose threatened ruptura uteri, the 
indication is to empty the uterus as quickly as possible, and further, 
this must be done with the least possible increase of intra-uterine 
tension. Forceps in head presentation, if the conditions are present. 
If not, cranioclasis. It is foolhardy to attempt a version in threat- 
ened uterine rupture. The child in these cases is almost always dead 
and the gain is therefore nothing for the immense risk. I w^ould 
advise in cases where the child is surely dead, to do cranioclasis as 
a primary operation. Extraction in breech presentation. Perforation 
of the head in hydrocephalus. Embryotomy in transverse presenta- 
tion. Do not attempt version here, the child is usually dead. Danger 
for the mother is too great. Caesarean section in absolutely con- 
tracted pelvis or where the soft parts are too narrow^ and hard. 
Symphysiotomy does not come up in the treatment of threatened rup- 
ture of the uterus. 

After rupture has occurred — six methods : 

(i) Expectancy, i. e., extract fetus, replace intestines, give 
■ergot, morphine, ice bag on abdomen. Some cases get 
well. 

(2) Drainage through rupture and the vagina, after delivery 

by the natural passages. Ergot, ice bag, morphine. 

(3) Sew up the tear from below and drain part of the tear 



•468 NOTES ON OBSTETRICS—SENIOR CLASS. 

with gauze ; after delivery of the child through the 
natural passages. 

(4) Delivery from below, and vaginal extirpation of uterus. 

(5) Laparotomy. Sew up rent, after removal of the fetus 

and placenta, cleanse cavity. 

(6) Laparotomy with amputation of the uterus, or total ex- 

tirpation, with or without drainage. 

The method giving the best results is : {i) Delivery of the child 
per vias naturales, also placenta. (2) Careful asepsis. (3) Force 
uterus down, vulsella in each lip, and (4) Sew the tear with silkwork 
gut, using long-handled needles. (5) Leave a roll of iodoform gauze 
in the lowxr angle of the wound, the one end in the peritoneum, the 
other in the vagina. (6) Fill vagina one-half full with gauze. 
Rest, morphine, ice bag, ergot. 

The first four methods mean that the delivery of the child through 
the vagina is possible. Sometimes it is not. In these cases you 
must do a laparotomy, remove the child ; then deal with the uterus 
according to conditions. If the woman is septic, amputate; if clean, 
sew up the tear; if tear too low for amputation, extirpate uterus, 
sewing vagina together, or draining through vagina. 

In incomplete tears, where just the peritoneum is left, clean out 
carefully and pack lightly with gauze. Careful not to tear through 
the peritoneal wall into free cavity. 

There still is much to learn about the treatment of ruptured 
uterus, and it will vary with the environment of the patient. If she 
is at home the treatment proposed is the best ; if she is in a hospital, 
perhaps laparotom}- would give best results. If septic, operations 
from below, even to extirpation of the uterus, are best ; if not infected 
her chances are good with either course of procedure, but the abdom- 
inal method gives more control over the hemorrhage. 

A very important question is that of removal to a hospital. In 
no case of threatened rupture may this be done, as the uterus may 
tear from the jolting. The patient must be delivered where she is, 
even if the facilities are poor. They must be improved. 

After rupture has occurred there is the same objection, but not 
in such force. The treatment of the case per vaginam, therefore, 
\n\\ be preferred, wherever it is at all possible. 

COMPLICATIONS ON THE PART OF THE INFANT. 

Asphyxia Neoivatorum. 

Asphyxia means "pulseless," but is applied to the child as to the 
adult, to express loss of life by the interference with the respiratory 
function. Danger to the life of the fetus in utero means danger of 
asphyxia in utero. The death of the fetus is almost always caused 



NOTES ON OBSTETRICS—SENIOR CLASS. 369 

by cutting off its supply of oxygen. There are other causes, but these 
are very few (e. g., syphiHs). 

The fetus' blood becomes more venous as the end of pregnancy 
draws near. This is due to the gradual narrowing of the ductus 
Botalli and ductus Arantii. The fetus, therefore, cannot stand a 
sudden increase of the venosity as well toward the end as earlier in 
pregnancy. This in accord with clinical experience. Children of 
the seventh month stand asphyxia better than at the ninth month. 
This may perhaps explain a popular notion that seventh month in- 
fants are more likely to live than those at eight months. It is not the 
increase of the COo in the blood which causes asphyxia, but the lack 
of O. The medulla becomes irritated by this lack of O, and a respir- 
atory eft'ort is made. It is the same mechanism that occurs when the 
child is born. The separation of the placenta causes such an interfer- 
ence with the circulation that no more O is in the fetal blood, this so 
irritates the center in the medulla that a respiratory effort is caused. 
If the child is still in utero when the attempt to inspire is made, 
the material near the child's mouth is sucked in, be it blood, me- 
conium or liquor amnii. This first inspiration dilates the capillaries 
of the lungs, and, unless there is something in the alveoli (e. g., air) 
to exert counter pressure, the capillaries may burst. We therefore 
find in fetuses that have died from intra-uterine asphyxia, ecchy- 
moses of the lungs and especially under the pleurae. If the acting 
cause of the asphyxia is a slow one, the respiratory center may be 
benumbed and the fetus may die without having made any attempt at 
respiration. These cases offer a bad prognosis, even if the child be 
d^elivered still alive. 

Cmcses — (i) iMaternal — (a) Disturbances of the utero-placental 
circulation, the result of pathological labor pains, e. g., in the stage of 
expulsion, long and continued pains, (b) Tetanus uteri (ergot), 
(c) Neglected transverse presentation, (d) Death or severe ane- 
mia, or asphyxia of the mother. The child dies first, it having been 
proved that the O in its blood is absorbed and used by the mother. 

(2) Fetal Causes — (a) Separation of the placenta, e. g,, after 
part of the body is extruded (in breech presentation), also prema- 
ture detachment of the placenta, (b) Compression of the cord, or 
prolapse of the cord, or around the neck, breech presentation, pla- 
centa compressed. (c) Compression of the brain — forceps, hem- 
orrhage, fracture, or compression from contracted pelvis. Death 
in the last case is due to, first, irritation of the vagus, therefore slow- 
ing heart, then paralysis of the vagus and very rapid heart. 

Symptoms — (i) In utero. 

(i) Increase of the fetal movements — then thev grow fee- 
bler. 
(2) Heart tones grow progressively slower, then suddenly 



370 NOTES ON OBSTETRICS—SENIOR CLASS. 

become uncountable. If they go below loo, suspicious, 
certainly if to 8d. During pains go to lOO, between 
pains 1 20. Then as case gets worse, during the pam 
to 90, between pains no to 120, then to 80, or they 
may go to 160 between pains. The irregularity of the 
tones also is important and the quality of the tones; 
the first sound may have lost its booming quality and 
become more valvular and like the second sound. 
(Only useful to acute observer.) 

(3) Passage of liquor amnii stained with fresh meconium: 

not thoroughly mixed with the fluid because this may 
be old. Sign of use in the second stage, or when the 
head is high up. Of no significance when have breech 
presentation, unless the breech is high up. The cause 
of the passage of meconium is an active peristalsis 
due to the asphyxia. It is common in asphyxiated per- 
sons to find that there is a passage from the bowels. 
It is not paralysis of the sphincter ani. In some nor- 
mal cases the meconium is found following the child. 
This due to the temporary asphyxia during the period 
of expulsion. Examination of a perfectly normal case 
as the head passes the vulva may show the heart tones 
80. It is a fact that quinine administered to the moth- 
er may cause the passage of meconium. The sign is 
not pathognomonic, as will be seen. 

(4) May feel, see and hear the inspiratory movements made 

by the child. 

(5) In breech cases can see the diaphragm move and can feel 

that the anus has lost its tonus, if fetus is dead. Time 

between the first respiration and the death of the fetus 

not definitely known. Varies from 3 to 15 minutes. 

It takes longer to drown (and this is drowning) a 

baby that has not breathed than one that has. 

Symptoms After Child Is Born — These, of course, depend upon 

the degree of the asphyxia, whether mild or severe. In the milder 

degrees the child is born, dark blue, sometimes purplish, the face 

is swollen, the conjunctiva injected, the eyes somewhat prominent, 

the skin may be a little pale around the nose and mouth, but the 

lips are deep blue. There is reaction in the muscles and they have 

not lost their tonus or may even be contracted. The mouth closes if 

you put the finger in the throat. The heart beat is slow but strong, 

and the cord is congested, a very few respirations at long intervals 

accompanied by a gurgling sound, the mouth and the trachea being 

full of mucus. If the face be sprinkled with cold water the muscles 

react and this is the sign of a mild asphyxia. If the child reacts to 



NOTES ON OBSTETRICS—SENIOR CLASS. 3ll 

stimuli the asphyxia is mild and the child will almost always recover. 
The condition is called Asphyxia Livida. 

Scz-ere Cases — The severe cases present an entirely different 
aspect. The child is pale, waxy, but the lips alone are blue. The 
body is limp, the extremities hanging down without any tonus at 
all, the jaw hangs relaxed, the throat does not react. There are no 
respiratory movements, or a very rare gasp which is very superficial 
and may be simply a movement of the jaw. The only evidence of 
life is a very weak and slow, or perhaps very rapid, heart beat. This 
may not be palpable, but audible to the stethoscope. The cord is 
limp, collapsed, the baby looks like a corpse. The criteria of this 
severer form of asphyxia are the absence of muscular tonus and the 
loss of reflex excitabiHty. This condition is called Asphyxia Pallida 
and is of much worse prognosis. 

Diagnosis — Not all children that are born in an apparently mor- 
ibund condition, are asphyxiated. Other conditions are pressure 
on the brain, anemia, and apnea, morphine poisoning. Brain com- 
pressions may be both the cause and the result of asphyxia. We 
have seen how it can cause asphyxia. In cases of asphyxia there is 
great cerebral congestion and the thin walled vessels of the brain 
sometimes burst and there is meningeal hemorrhage. 

The diagnosis of cerebral compression is very hard and the 
character of the labor must be the guide. A hard forceps, or extrac- 
tion, in which it is knowm that injuries to the skull have been made; 
examination of the skull may show a fracture or a dislocation of 
the plate of the occipital bone on the condyles. Usually you have to 
treat the cases as asphyxia. The post mortem clears the diagnosis. 

The diagnosis of anemia can only come from a study of the 
labor because an anemic fetus looks like asphyxia pallida. Rupture 
of a vessel from a velamentous insertion of the cord. Tearing of the 
placenta in placenta previa, cutting it in Caesarean section. 

The diagnosis of apnea — in a few minutes the child breathes. 
The heart beat is strong and regular, the features gradually become 
blue, a few superficial respiratory movements, then a gasp, or a 
sneeze, which brings the mucus from the air passages, and finally a 
cry. 

Morphine poisoning. Of course, very seldom and usually not 
considered. Child is revived, breathes, cries, opens eyes and then 
relapses into sleep, repeats the process when awakened. 

The Prognosis — In the milder of degrees of asphyxia is good if 
properly treated. Almost always get well, unless there is some other 
accident, e. g., cerebral hem.orrhage. In asphyxia pallida the prog- 
nosis is not so good, but if no other cause than the asphyxia the 
majority get well if properly handled. 

An interesting subject and one that is by no means cleared up. 



372 NOTES ON OBSTETRICS—SENIOR CLASS. 

is the relation of asphyxia to mental diseases in later life. Cases are 
on record where idiocy developed in the first years of life after 
asphyxia, or long labors, or severe forceps operations. The evidence 
is sufficient to make us strive to avoid all the causes of asphyxia, to 
bring the child back to life as quickly as possible and make the 
recovery positively sure. 

Treatment — Important to distinguish between the milder and the 
severer forms of asphyxia. Up to a certain point the treatment is 
the same for both cases. When the child is still in utero the indica- 
tion is for rapid delivery. We have no means of treating asphyxia 
in utero. If conditions for forceps — forceps ; if a breech — extrac- 
tion ; version and extraction. In every labor where it is foreseen that 
the child is likely to be asphyxiated, preparations for the same must 
be made — a hot bath, and plenty of hot water. Bath thermometer. 
Bath loo to no. Hot towels, a suitable table, one or two tracheal 
catheters or a balloon catheter. As soon as the child is born you 
must determine the severity of asphyxia. Wipe the mucus from its 
mouth and throat. If the throat reacts (you can feel it close on the 
finger) it is a mild asphyxia, if not it is severe. 

In general there are three points in the treatment, after the 
child is born: (i) Keep up the body temperature. (2) Remove 
foreign bodies from the air' passages. (3) Start respiration, or 
practice artificial respiration. 

Methods — (i) As soon as the child is born, it is tied off, 
wrapped in hot towels. Keep it covered as much as possible in the 
subsequent manipulations. If possible, carry out part of the manip- 
ulations in the hot bath. This part not to be forgotten. (2) Re- 
move foreign bodies in the air passages. If the asphyxia is mild it 
usually suffices to wipe the mucus from the throat, and to hold the 
child up by the legs-, its head touching the table, and pat it gently 
upon the chest. If this is not sufficient, use the tracheal catheter. 
No. 14, French scale, is the proper size. Passed into the larynx. 
It is usually not necessary to go deeper than the vocal cords, but if 
the chest does not expand when the fetus inspires one may conclude 
that the bronchi are filled and then it is necessary to pass the cathe- 
ter down to them. Suck out the fluids and re-insert if there appears 
to be more. If gently carried out there is no harm done. In the 
absence of a catheter use a towel. The balloon catheter is not very 
good. (3) Stimulate respiration. In the milder asphyxia all that 
is necessary after the clearing of the passages is to rub the child 
vigorously, or spank it, or put a few drops of cold water on its chest 
while it is in a Hot bath. Almost always these simple methods suc- 
ceed. The rubbing should be all over the body so as to prevent epi- 
dermis in one place from being rubbed off. Should the child present 
the condition of asphyxia pallida these methods do no good because 



NOTES ON OBSTETRICS—SENIOR CLASS. 373 

the respiratory eenter is not in a condition to receive stimuli. Yon 
must supply oxygen to it until the center has become active. There 
are numerous methods of artificial respiration : 

(i) Sylvester's method (preferably m the hot bath). 

(2) Byrd's — Fold child up like a book, 20 times to the minute. 

(3) Hold the child up by the legs while you compress the chest 
symmetrically and rhythmically. 

(4) Schultze swingings. Only after all the other methods have 
failed or where you see from the start that it is inadvisable to waste 
any time on less certain methods. This is at the same time the most 
dangerous and most certain method. Grasp the child with the head 
between the two wrists, the fingers spread over the back, the thumbs 
in front at either side of the chest, the index finger under the axilla 
to prevent the child from flying out of your grasp. Now lift above 
the head, gently, let the legs hang down — this is expiration. Now 
swing out and forward, letting the child come between the legs, not 
too strong. You must hear the air enter the chest. Repeat the 
maneuver slowly 6 to 8 times, put the baby in a hot bath and note 
the effect on the pulse and respiration ; if none repeat the swingings. 
Dangers — rupture of the liver or spleen, hemorrhage into the supra- 
renal capsules, etc. 

(5) Catheter for hisuiflation of Air — This must be done very 
gently, with the force of the cheeks only and with the air that has not 
been drawn into the lungs. The balloon catheter has been used for 
this purpose, but there is greater danger of rupture of the alveoli. 
Pure oxygen should be used if obtainable. 

How long to keep up the attempts at resuscitation? The rule is 
as long as the heart beats, but sometimes the heart will beat for 
hours, if there is enough O in the blood. If due to a cerebral hem- 
orrhage, this is possible for hours. Question if trephining could not 
be resorted to in some cases. 

Treatment of Asphyxia Neonatorum: Summary — Forceps ex- 
traction ; version and extraction. 

(i) Remove the child to air as quickly as possible. 

(2) Keep up the body temperature-^— hot bath, keep covered, 
warm towels. 

(3) Remove foreign bodies from bronchi — inversion of child, 
wipe pharynx, catheter. 

(4) vStimulate respiration : 

(A) In asphyxia livida (mild cases) — 
■ I. Rub child vigorously. 

2. Spank it. 

3. Hot bath and few drops of cold water, 

(B) In asph\'xia pallida (severe cases)^— = 

I. Sylvester's method, 



37-4 NOTES ON OBSTETRICS—SENIOR CLASS. 

2. Byrd's method. 

3. Compression of the chest and inversion. 

4. Schultze swingings. 

5. Mouth to mouth insufflation (catheter). 

As a routine practice in cases of asphyxia it is advisable to clear 
the passages, with the catheter. Then place the infant in a hot bath 
and watch it a minute. If it gasps, or if there are tiny respirations, 
wait, keep the water hot ; if the child grows worse, compress the chest 
for a few times ; if no effect, Schultze swingings, and later blow air 
or oxygen into the chest with the catheter. 

Laborde's tongue traction, dilation of sphincter ani, medication, 
will not save the child if the above methods prove unsuccessful. 
After recovery from the primary asphyxia the attendant must watch 
the child carefully. It sometimes develops a secondary asphyxia, 
due to atelectasis pulmonum, which is usually fatal. Treatment 
similar to above. 

OPERATIVE OBSTETRICS. 

During a labor the accoucheur's duty is usually one of watchful 
expectancy. He simply studies the course of nature, and observes 
when and where he may be of assistance. He is not to render any 
"assistance" unless there is something wTong in the course of the 
labor, or some danger threatens either mother or babe. Under such 
circumstances he must interfere. He makes up his mind, first, that 
he must do something ; second, what he is to do ; third, when he is 
to do it. These three questions require a close study of the indica- 
tions and a delicate balancing of the conditions in each case. Hav- 
ing determined that there is an indication for interference, a few 
words about obstetric operating in general. 

1. The indication must be clear and distinct. Never operate to 
save time, nor to satisfy the desire of another practitioner ; never to 
quiet the clamor of the friends, or the patient, nor for glory. The 
last is especially true of the graver operations, e. g., Caesarean sec- 
tion, symphysiotomy. 

2. Asepsis must be absolute. Even in poor quarters this can be 
attained, of course wath considerable trouble, but the conscientious 
physician will not spare this. If a serious operation is indicated the 
patient should be taken to a hospital whenever possible. If there 
is not the time or there be no hospital nearby, one must try to ap- 
proximate hospital conditions at home, which may be done to sur- 
prising degree with a little work and a will. 

3. The selection of the operation will depend on the indications, 
but sometimes it will hang on your skill, e. g., it may come to decide 
between craniotomy and Caesarean section. A skilled hand may 
prefer the section when the conditions for both are about evenly 



NOTES ON OBSTETRICS—SENIOR CLASS. 375 

balanced. Do not underrate the gravity of obstetric operations be- 
cause you will grow careless, and, too, do not overrate the dangers 
because then the mother or the child may suffer while you hesitate. 

4. The question of assistance is an important one. It is unjust 
and cruel to give the obstetric patient less efficient service than the 
gynecologic patient. In simple perineorrhaphies there are usually 
two assistants, besides the nurse, and this ought to be the rule for 
obstetric cases. In practice this is usually impossible, but there 
should be at least one assistant for the anesthetic, the nurse and the 
husband, if he can stand it, or a courageous neighbor. 

5. Before each operation that is out of the ordinary, read up on 
the case, get the plan of procedure clearly in your mind. In all cases 
just before operating do the various steps first in the air before the 
patient, and review the possible complications. Be ready, however, 
to alter the whole plan of procedure at any stage, if necessary. 

6. An accurate diagnosis, re-affirmed after the patient is on the 
table and asleep. It may be necessary to desist from operating and 
put the patient back to bed, or select another plan entirely. Do not 
go through with the original plan if you find things different than 
expected to save yourself trouble or mortification. Usually you will 
get more of each if you do so. 

7. After every operation, mild or severe, examine the patient 
carefully — uterus, lower uterine segment, cervix, vagina, perineum, 
to discover any and all injuries to the parturient canal. You must 
positively kiiozi' and record the number and extent of the puerperal 
wounds. 

Kinds of Operations — Obstetric operations are of two kinds ; 
first, those that deliver the child ; second, those that prepare the parts 
for deliver}-. Some operations are in both classes, e. g., symphysi- 
otomy. 

In the first class we consider extraction: (a) by the breech; 

(b) by the head. 

In the second class there are: (a) turning the child from one 
presentation to another; (b) changing the position of the child; 

(c) changing the attitude; (d) enlarging the passages, soft and 
hard; (e) making new passages; (f) inducing labor, etc. 

Extraction — Extraction means the artificial removal of the fetus 
from the uterus. This may be through the genital passages, or the 
abdominal wall, or may mean extraction by the head or by the 
breech. May mean extraction entire, or after mutilating the fetus. 

We will lirhit the term to the extraction of the fetus through the 
natural passages without any diminution of its size. Thus we may 
have extraction by the head or by the breech. Before taking up 
either, however, we will study the indications, conditions, etc., for 
extraction in general. 



376 NOTES ON OBSTETRICS—SENIOR CLASS. 

Why should we want to extract? 

Why should we want to terminate labor? 

Because certain conditions exist which command the termina- 
tion of labor and the woman herself cannot do it. Here is the idea — 
Insufficiency of the powers of labor; this is the reason we extract. 

The problem is not perfectly simple because we find many kinds 
of conditions surrounding a case. These will usually be ranged 
under one of the following heads. 

I. The Powers — The parts are normal, the fetus is normal (i. e., 
normal resistances), but the woman cannot deliver the child. This 
is weakness of the powers of labor. In these cases the pains are 
few and far between, weak and short. 

II. The powers may be normal, pains good and strong or even 
stronger than normal, but there is some increase in the resistances. 
Either the fetus is too large or the pelvis too small, and labor cannot 
be terminated by nature. These are cases where the powers are 
relatively weak and need assistance from art. 

III. The powers are normal, the parts are normal, the fetus is 
of normal size, but some accident has happened, e. g., prolapse of 
the cord, or eclampsia, and it is highly desirable that the labor be 
terminated rapidly, more rapidly than nature w^ould do it. This is 
relative weakness of powers due to some complication. 

Under extraction we consider — 

( 1 ) Extraction by the head — the forceps operation ; 

(2) Extraction bv the breech — pulling on the body of the 

child. 
The simplest form of extraction is the assisting of nature in 
breech cases — when the breech of the child has been delivered. 

MANUAL AID. 

Breech labors are normal labors. The fetal and maternal mor- 
talities are higher than in the head labors, but the large majority of 
cases terminate spontaneously, therefore eutochia. Formerly breech 
labors were considered very bad for the child and it was stated 
that 25% to 30% died during delivery. Even as late as '93 the mor- 
tality was given as 10%. This is not so. When there is a high 
mortality it is usually due to errors of art. 

That the fetus runs greater danger than in head presentations 
is evident and in a very large number of cases the mortality would 
certainly be higher. This is due : 

1. To compression of the cord between the body of the child 

and the soft parts. Occurs as soon as the navel passes 
the vulva. 

2. Premature detachment of the placenta because of empty- 

ing of the uterus. 



NOTES ON OBSTETRICS— SENIOR CLASS. 377 

3. Pressure of the hard head against the placenta. In head 

cases the soft breech presses against the placenta. 

4. After breech is expelled, a large portion of the fetus is 

exposed to air, therefore respiratory stimulation, and the 
head is still in utero — different when head is delivered. 

5. When the soft parts of the mother are poorly prepared, 

and this is likely because the small and soft breech does 
not dilate them as much as the head ; there may be de- 
lay when the shoulders come to pass through or with the 
exit of the head. Of course this delay aggravates all 
preceding- causes. 

6. In cases where traction is exerted on the body too soon, 

the arms may be . stripped up above the head and the 
delay necessary to bring them down may kill the child. 

7. The cervix may close down on the neck, really buttonhol- 

ing the head in the uterus. Due to too early attempts at 
extraction, or too much manipulation. 

8. Finally, children may not live after delivery, because of 

sepsis or injury. 

For the Mother — There is danger of laceration of the tissues — 
cervix, vagina, perineum — due to too rapid extraction in imper- 
fectly prepared parts, or to the necessary manipulations (sepsis). 

Treatment — The treatment of normal breech presentation is 
"watchful expectancy." If no indication arises for the termination 
of labor, wait. Do not rupture the bag of waters — ''preserve the 
integrity of the fluid wedge." Watch the heart tones or feel the 
pulse in the child's foot. If meconium comes away it is of no im- 
portance, being simply pressed out by the increased intra-uterine 
pressure. Finger in the anus also shows the life of the fetus. When 
the second stage is begun — lithotomy position, preferably on a table, 
but usually across the bed. Have everything ready for asphyxia 
neonatorum. No chloroform, generally. 

I. After breech is delivered tell woman to bear down strongly. 

II. Assistant presses the uterus down firmly, if she cannot or 
will not bear down, e. g., during operation or under anesthesia. 
This is to prevent the arms from being stripped up over the head. 

III. If the child does not make rapid progress, it is necessary to 
render manual aid. Seldom necessary in multiparae, frequently in 
primiparae. Have an assistant make continuous even pressure over 
the whole uterus, from the outside. Take the breech in two hands, 
thumbs over the back, fingers grasping thighs and pelvis, make even 
traction downward, in the axis of the inlet. Pull down a short loop 
of the cord so that it may not be pulled on by the fetus. 

Gentle traction combined with steady supra-pubic pressure till 
the anterior shoulder blade becomes visible or palpable under the 



378 NOTES ON OBSTETRICS—SENIOR CLASS. 

pubis. Now grasp the feet of the child, and swing them through 
an arc, toward the side on which the belly of the child lies, with the 
other two fingers, pass over the back of the child to the shoulder, 
over the shoulder down the humerus, to the elbow, then wipe the 
extremity over the face and chest of the child. The lifting of the 
fetus up to the side rotates the shoulder into the hollow of the sac- 
rum, or, at least, gives more room to insert the hand. After this 
arm is delivered, rotate the child in the opposite direction, changing 
the operating hand, at the same time it may be necessary to turn the 
baby's chest bodily so as to bring the other shoulder posteriorly. 
The delivered arm is laid alongside the chest as a splint, the index 
finger is laid over the scapula of the other arm and the chest 
grasped full in the spread fingers. Then with gentle stuffing and 
rotary motions, pushing on the scapula with the index finger, the 
chest is rotated so as to bring the second arm behind. Leave the 
thumb outside during all these maneuvers, on the back, never inside 
the vulva. After the arms are delivered the hardest part is accom- 
plished. Head enters inlet as shoulders pass outlet. 

Deliver the head according to the natural mechanism. 

Head passes through the pelvis best if well flexed. To aid this 
have the assistant keep up firm pressure on the fundus uteri. Put 
child astride your arm, two fingers in the mouth, and flex chin on 
sternum. Two fingers now pass over the nape of the neck to the 
sternum and traction on both hands together in the line of the inlet. 
Pull down till the nape of the neck is well under the pubis, now 
stand off to the side and lift up the child, still keeping the chin well 
flexed. Chin, face, forehead and occiput are delivered over the 
perineum. 

During the delivery of the head the danger of asphyxia is slight 
and you must protect the perineum, therefore deliver slowly. In 
primiparae may perform episiotomy, but if vou have the labor well 
in hand it is not necessary. For your first cases do it. 

This method of delivery of the head is called the Smellie-Veit. 
It was first used by Mauriceau. Smellie modified it, its place was 
taken for a time by others, then Veit published a work on it which 
brought it into popularity. There are many other methods, but this 
is one of the best. Wiegand-Martin method also good. 

Manual aid is the simplest operation under extraction. It is 
simply aiding nature to expel the fetus when it is passing breech 
first and the resistances are a little too great, causing delay in the 
delivery of the shoulders and head, which is dangerous for the 
fetus. 

Treatment, then, of breech presentation is (i) watchful expec- 
tancy till the navel has been delivered ; then (2) have woman bear 
down; (3) assistant presses on the whole uterus; (4) manual aid. 



NOTES ON OBSTETRICS—SENIOR CLASS. 379 

TREATMENT OF BREECH PRESENTATION WITH 
BREECH NOT ENGAGED. 

In cases where the breech has not engaged remember that the 
breech normally remains high np for a long time. That it usually 
comes down with the rupture of the bag of waters late. That when 
it becomes necessary tq deliver the child the case is pathological and 
must be strongly differentiated from those requiring ''manual aid" 
simply. 

Indications — For interference when the breech is high up are the 
same as for extraction in general : 

(i) Insufficiency of the powers. Weak pains, mal-development 
of the uterus, poor innervation, rupture of th^ uterus, death of the 
patient. 

(2) Relative insufficiency of the powers of labor, due to increase 
of the resistances on the part of the mother or of the child. 

(a) On the part of the mother — 

Rigidity of the cervix, vagina, perineum, e. g., young 
primiparae or contracted pelvis, e. g., generally con- 
tracted pelvis. 

(b) Unusual size of the child, mal-position, etc. 

(3) Insufficiency of the powers in relation to the necessary rapid 
termination of labor, i. e., 

(a) Some complication, e. g., eclampsia, sepsis, acute and 

chronic heart and lung diseases, pneumonia, etc., hem- 
orrhage. 

(b) On the part of the fetus, asphyxia from any cause. 
The Conditions — 

1. Bag of waters must be ruptured. 

2. Cervix effaced and os dilated. 

3. Pelvis not too contracted. 

"2." Cervix must be effaced and os dilated — These conditions 
are important in relation to ease of extraction, the integrity of the 
maternal tissues and the life of the child. Sometimes necessary in 
the interest of the child to operate without this condition ; then 
dilate cervix, or incise it. 

"3." The pelvis must not be too contracted. A conjugata vera 
under 8 cm. will seldom allow a normally developed full term child 
through. With a conjugata vera of 8 cm. operation is difficult; 
over 8 cm. the chances are better. In a generally contracted pelvis 
the figures are all ^ cm. higher. 

Method of preparation will reserve for consideration under For- 
ceps. 

Operation — Operation divides itself into four stages or acts : 



380 NOTES ON OBSTETRICS— SENIOR CLASS. 

1. Extraction of the breech or foot to the navel. 

2. Extraction up to the shoulder. 

3. Bringing down the arms. 

4. Delivery of the head. 

Treatment of the First Act — The method of treatment of the 
first act depends upon the presentation. If a footling presentation, 
or if you have done a version, the foot being brought down, the 
extraction is made on the foot. It is not necessary to have the two 
extremities. Better one should lie with the breech so as to dilate 
cervix more. 

Method — Grasp leg with two hands, thumbs parallel to the long 
bones. Traction downward in the direction of the axis of the inlet, 
intermittent and witn the pains. If the traction is parallel with the 
long axis of the limb and with the body and in the line of the axis 
of the inlet, if done slowly, there is hardly any danger of producing 
a luxation of a fracture, if otherwise, fractures are common. As 
the limb appears the hands grasp the part higher up. When the 
anus appears, traction must be more horizontal — the breech turns 
upward of itself. Now possible to put the finger over the back down 
the crest of the ilium into the opposite groin. This aids the extrac- 
tion and favors rotation of the back to the front. Use care not to 
fracture the femur. When hips are delivered continue the tractions, 
slowly, with the pains and let the other foot fall out itself. If the 
cord is around the buttocks or between the legs, slide it over one of 
the nates. 

If too short, cut between two artery forceps. After navel appears 
first act is ended. When the case is a complete or double breech or 
a single breech, ''mode de ferses," there are several methods of com- 
pleting the first act of extraction : 

(i) Bring down a foot — 

In cases where the breech has not yet engaged and there is some 
immediate danger or prospective indication for the rapid termina- 
tion of labor, the method of election is to go in and bring down a 
foot, on which the extraction is done. 

Method — Preparations the same, as for version (later). 

Hand to use — Rule: Take that hand which, when placed in the 
uterus, will have its palm directed toward the part to be g^rasped. 
thus in Sac. L. A. left hand, in Sac. D. P. right hand. Hand is 
formed into a cone, well lubricated, and passed through the vulva 
with a boring motion, through the cervix into lower uterine segment. 
If the case is one of double breech it is easy to get a foot and perhaps 
only necessary to pass two fingers into the cervix. 

Ride: Grasp the anterior foot, i. e., the one nearer the anterioi 
wall of the uterus. If the case is one of single breech the hand must 
pass quite high up, as far as the knee. Flex the leg on the thigh bv 



NOTES ON OBSTBTRICS—SENIOR CLASS. 381 

putting the index finger in the popliteal space and sliding the other 
fingers down the leg till the ankle is between the fingers. Now 
draw the foot slowly down into the vagina, along the side of the pel- 
vis, or somewhat posteriorly. This procedure is advisable in cases of 
contracted pelvis and in breech presentations with pendulous abdo- 
men. There are other methods which may be used. 

(2) The Finger in the Groin — This should be limited to cases 
where the breech is wedged so tightly in the pelvis that it cannot 
be displaced to get a foot. It is to be preferred above the use of the 
fillet, or the forceps, or the blunt hook. Almost always possible to 
get down a foot if care and patience be used. 

Method — Preparations same as for version, etc. Whole hand 
passed into the vagina. In Sac. L. A. the right hand, later the left. 
One finger, never more, passed into the groin from before back- 
wards. Support the wrist with the other hand. Use the sec- 
ond finger when the first gets tired, then change hands. In a primi- 
parae with tight perineum and vagina this is by no means an easy 
operation. Hands get very tired. As soon as you can reach the 
posterior groin, put a finger in that also, and now the operation is 
simple. Remember that time is no factor, also that sometimes a 
slight vis a fronte is sufHcient to start the breech. When the breech 
is delivered, let the legs alone, they will drop down themselves. 

Advantages of this method are that there is little danger of 
injuring the fetus, cutting the skin, tearing the vessels in the groin, 
or opening the belly. Finger the gentlest tractor. You may frac- 
ture the neck of the femur, if the traction is not applied properly. 
Pull tow^ard the fetal body so that there is no pressure on the neck of 
the femur. 

(3) Use of the Fillet (or sling). 

An ordinary tape may be passed around the thigh in the groin. 
May use a ring to which the tape is tied, or a sling carrier, of which 
there are many forms. All are open to the same objection — danger 
of fracture of the femur, tearing of the skin of the groin, laying 
bare the femoral vessels, and unnecessary. A smooth ring is tied on 
the corner of a silk handkerchief, making a good fillet for the 
purpose. 

It is passed from the back through the groin, well down between 
the thighs ; then bring the ring out by the finger passed between the 
thighs. Traction similar to that with the finger, down and back- 
ward toward the body of the child, so as to avoid breaking the femur. 
When the hips are so far descended that you can reach the other 
groin, insert the finger in that, pass the finger from behind over the 
crest of the ilium to the groin. Never use the blunt hook, except 
on the dead child. Same said of the breech forceps, which really is 
a pair of blunt hooks. The forceps is not to be applied to the 



:382 NOTES ON OBSTETRICS— SENIOR CLASS. 

breech. Danger of slipping off, fracture of the pelvis, third, inef- 
ficient. 

We have now considered the methods of completing the first act. 
To sum up : 

(i) Traction on the leg, if a footling, or after a version. 

(2) Bring down a leg in complete or single breech. 

(3) If breech too firmly fixed, traction on it by means of 

one finger in the groin, or the fillet. 

Iron hook, the forceps, the breech forceps, not to be used unless 
the fetus is dead. 

The second, third and fourth acts of extraction have been already 
described under Manual Aid. It remains to go over the various 
difficulties that can arise during the operation. 

During the first act — 

Bringing down the posterior foot, the anterior hip catching on the 
symphysis — obstruction to delivery. Sometimes the first leg crosses 
the second, which lies athwart the pelvis. 

Treatment — Put a sling on the ankle delivered, bring down the 
other foot, and extract on the two feet. 

During the second act — 

Usually no difficulty arises, unless it be a large, fat baby. Care- 
ful where the pressure of the finger is put, because danger of rupture 
of the liver, or the full colon. If there is difficulty, examine to see 
if there is a monster. 

Important clinical hint — 

With large babies and contracted pelves, do not pull out trunk 
till the anterior scapula becomes visible, because then the baby's 
head will wedge the arms, which are often stripped up along the 
head, into the pelvis and make their delivery difficult, perhaps im- 
possible, therefore begin the third act sooner. Necessary to put the 
hand in further, wherefore use whole hand. There is danger of 
lacerating the perineum by the hand and fetus together. Episiotomy. 

Third Act — Greatest difficulty generally here. In normal cases 
the arms lie folded across the chest and appear with the thorax. 
If traction is made on the trunk, and if the assistant does not keep up 
pressure on the fundus the arms may be arrested at the inlet and 
be stripped up alongside the head. Due also to an undilated cervix. 

Treatment — Same as usual, but use four fingers, go high up into 
the pelvis, posterior arm first. Be sure to be at the elbow and push 
the arm to the other side of the pelvis and into the hollow of the 
sacrum, over the face of the infant. 

Not allowable to pull down shoulder to make arm more acces- 
sible. Be sure the arm is posterior, lift up the fetus well. If after 
repeated trials you do not succeed, or there is danger of breaking 
the arm, turn the chest around and bring down the other arm. After 



NOTES ON OBSTETRICS—SENIOR CEASS. 383 

this is delivered bring down the first arm, turning the chest again. 
Done slowly and carefully it is usually successful. 

A second complication of the third act is where the arms are 
thrown back into the nape of the neck and cross the pelvis under the 
head. These are bad cases. 

Treat]uciit — The assistant should desist from pressing on the ab- 
domen. 

(i) With hand as far as possible behind, try to push the elbow^ 
over the face, taking first that arm which is more posterior. 

(2) Turn the child around, passing in two fingers from in front, 
and pushing, not pulling, on the shoulder with these two fingers, so 
as to bring the arm behind, where there is more room. 

(3) If this does not succeed, turn the other side and try to 
deliver the anterior arm and shoulder first, by turning it posteriorly. 
/\id all maneuvers by pressure on the arm and head from the outside. 

In both these complications, if you do not succeed in delivering 
the arms it may be necessary to deliver them by brute force and run 
the risk of breaking them. (Bad.) 

Complications During the Fourth Act — 

A. Head arrested at the inlet. — Occurs in contracted pelves and 
with large babies and hard heads. Antero-posterior diameter of 
head in transverse diameter of pelvis. 

Treatment — 

(i) Smellie-Veit and jMartin-Wiegand methods, remember- 
ing: 

(a) Mouth high up to one side. 

(b) Head not to be too strongly flexed. 

(c) Rotation not to be effected till the head is well in 

pelvis. 

(d) Pull in the axis of inlet. 

(2) Pressure from the outside on the head, with 

(3) The Walcher position. 

(4) Push head slightly to one side to bring biparietal diam- 

eter to side of promontory. 

In difficult cases use all four. Some authors advise the use of 
the forceps in these bad cases. Objections are: 

There is generally very little time, child almost dead ; it is hard 
and dangerous to mother ; and not adapted to this class of cases, 
because the head is above the inlet. If the head will not come into 
the pelvis in spite of justifiable traction and pressure, stop efforts 
to deliver. Do not tear the woman to pieces, or the child's head 
off. Now there is no occasion to hurry. May leave case to nature 
or do craniotomy. Child almost always dead by this time and in 
other cases is lost beyond recovery. 

B. In rare cases the head may be arrested at the pelvic floor. 



384 NOTES ON OBSTETRICS—SENIOR CLASS. 

Usually the head comes out too fast and the perineum is torn, there- 
fore it is sometimes advised to do an episiotomy (primiparae). If 
there is resistance at the pelvic floor, do episiotomy to save the child. 
Sometimes necessary to do forceps and especially if the outlet is 
contracted (masculine pelvis). Rare, but if indicated is justifiable 
to use forceps here. 

All these anomalies may occur with the breech extraction when 
the rotation of the breech is normal, i. e., with the back to the front. 

We now take up — 

Abnormal Rotation in Breech Presentation — For the normal 
mechanism of breech presentations it is necessary for the back to 
rotate anteriorly. This brings the arms into the hollow of the sac- 
rum, where there is more room, the occiput to the pubis and the 
head may now be easily delivered. In some breech deliveries the 
back turns to the mother's back, the child's belly looks up toward 
the pubis. 

This occurs — 

(i) In footling presentations, when the posterior foot has 
come down ; 

(2) After versions by the foot, when the posterior foot is 

brought down ; 

(3) Rarely during an otherwise normal extraction of the 

breech by improper attempts at rotation. 

In footling presentations when the posterior foot is down, the 
usual mechanism is that the back rotates three-fourths of the circle, 
past the promontory of the sacrum to the opposite side of the pelvis 
and a normal back anterior presentation results. The back rotates 
in the opposite direction from that which one would expect. 

During an extraction, therefore, when you notice this, do not try 
to oppose the rotation but seek to aid it. By not appreciating this 
point and resisting the mechanism sought by nature, the back may 
remain directed behind. During the first and second acts this is of 
little moment. You watch the rotation intended by nature and seek 
to aid it by pulling harder on the groin, which tends to turn forward. 

Third Act — Bring down the arms. 

If these are across the chest, usually little trouble. Same rule 
as usual but go in from behind (the back being here), and get the 
arms down behind the pubis and out over the front of the chest. 

If the arms are thrown up along the side of the head great difli- 
culty is met. 

Under no circumstances bring down the arms over the back of the 
fetus, always in front, and use the same rules as in normal rotation, 
but reversed, i. e., from behind forwards. 

Fourth Act — Delivery of the head : 

Here often great trouble arises, but sometimes labor may termi- 



NOTES OX OBSTETRICS—SENIOR CEASS. 385 

nate spontaneously. Chin flexes on the sternm, nape pivots on peri- 
neum, chin, face, forehead appear from under the pubis and finahy 
occiput comes out. If necessary to aid nature, aid in this way — 
SmelHe-X'eit upside down. 

Should the chin be too far up and off to one side, may try to 
bring the face behind. 

La Chapelle's Method — Half hand passed in from the side op- 
posite to which the chin lies, and on retracting hand try to pull face 
with it. Rarely successful, but should be tried and combined with 
external manipulation. De Lee's method — Hand on occiput exter- 
nally, two fingers on face inside, get a purchase on the malar bone. 
and pushing the face to the back the outside hand pulls occiput for- 
ward at the same time. 

Van Hoorn's Method — Lift the child up towards the mother's 
belly, flexing body over the pubis, occiput comes out, then forehead, 
face, chin last : front of the neck pivots behind the pubis. This is 
an imitation of nature's method in some of these cases. 

In these cases the forceps may be used if there is time and the 
child is surely still alive. ' 

N'ofe — The delivery has been described as it is when the course 
is pathologic throughout, but at any point in a pathologic delivery it 
may become normal, and likewise a normal delivery may at any 
time become pathologic. 

First two acts to be done slowly. 

Think out the whole mechanism yourself first. 

Last two acts, carefully but quickly. Four minutes for the arms, 
four minutes for the head. More time lost is dangerous. Children 
sometimes live after five minutes' compression of the cord, but as- 
phyxia is often profound, resulting in atelectasis, pneumonia, sepsis. 

CERVIX COMPLICATIONS. 

Finally should be mentioned complications on the part of the 
cervix. 

If extraction is undertaken when the cervix is still undilated 
there is danger to the fetus and the mother. 

For the Mother — If the cervix tears, hemorrhage in the third 
stage. Especially in placenta previa. Later sepsis. Rupture of the 
uterus. 

For the Child — Arms may be stripped over the head, and delay 
in their delivery kill the infant. After the shoulders are delivered 
the cervix may close down on the neck, buttonholing the head in the 
uterus. 

Causes — 

1. From brusque manipulation. 

2. Frequent attempts at delivery. 



386 



NOTES ON OBSTETRICS—SENIOR CLASS. 



3. Too much fingering in cervix. 

4. Extraction when cervix not well dilated, and it is more com- 
mon in footling presentations than in double breech. 

With the causes you have the prevention : 

If the cervix gets around the child's neck, traction on the child 
brings the cervix into view as a purplish band. Try to strip it back 
over the head. If impossible, incise it. Careful about extracting 
forcibly. Let the fetus get air by holding back the soft parts with 
a speculum and with the fingers, allowing the air to get to the mouth. 
Schroeder did so for 20 minutes. Stowe advises tracheotomy. 
Indication may arise, but rare. 



SCHEME. 



Breech 
Deliveries. 
Normal cases. 
Manual aid. 
Abnormal cases. 
Extraction. 
Indications : 

I. 

2. 



COMPLICATIONS WITH 
NORMAL ROTATION OE 
BACK. 



I. 



foot 



brought 



III. 



IV. 



Conditions : 
I. 



2.- 



II. 

III. 
IV. 



Operation, 
four stages. 
I. Footling. 
Breech. 

a. Bring down foot. 

b. Einger in groin. 

c. Sling. 

d. Hook. 

e. Eorceps. 
Dead 
child. 

II. Deliver to shoulders. 
III. Delivery of shoulders. 
IV. Delivery of head. 

THE EORCEPS OPERATION. 

History — (Schroeder.) 181 vears since first pair of forceps 
was published. 



Posterior 

down. 

II. Big,- fat baby, small pelvis. 

Arms high up ; arms in 

nape. 
Head arrested at inlet. 
COMPLICATIONS WITH 
ABNORMAL ROTATION 
OE BACK. 

I. Post. foot. Try to rotate 
back in the direction 
sought by nature. 
Same. Try to rotate as in 

No. I. 
Arms high — nape of neck. 
Head with chin on pubis. 

a. Mauriceau - Smellie - 
Veit upside down. 

b. La Chapelle method. 

c. De Lee's method. 

d. Van Hoorn's method. 

e. Forceps. 

f. Craniotomy. 
Resistance from the cervix 
Resistance from the perineum. 



NOTES ON OBSTETRICS—SENIOR CLASS. 387 

Cause — Midwives had obstetrics. Men called only to the worst 
cases. On the other hand, the physicians were not regarded as of 
much account, as they could render but little aid when they were 
called, ''and this expedient," says Smellie, ''raised a general clamor 
among the women, who observed that when recourse was had to the 
assistance of a man-midwife, either the mother or the child or both 
were lost." This feeling is still prevalent among foreigners and the 
uneducated. 

In the last of the i6th century, the surgeons of note, especially 
in France, began to study and practice obstetrics, and the need of an 
instrument which would deliver a head impacted in the pelvis was 
sorely felt, and as soon as it was invented the position of the surgeon 
as an accoucheur was raised very high and the midwives were rele- 
gated to their proper position, as aids in normal labor cases only. 

Obstetricians preferred to be called to cases where the position of 
the baby was pathological, e. g., transverse presentations, or breech, 
since here they could turn the child, or pull on a foot ; whereas, by 
the head they had no means of extraction. Thus is it not surprising 
that the idea of the forceps was so long in coming ? Hippocrates had 
advised in such cases to pull on the head with the hands. Pierre 
Franco, in 1561, advised the use of a three-bladed duck-bill specu- 
lum to grasp the head with. Smellie advised the use of fillets, brought 
with great difficulty over the head. The Japanese use such appli- 
ances even now, introduced with pieces of whalebone ; they also use 
a silk net. (Kangara, 1832.) 

Finally, in 1723, Palfyn, a surgeon and anatomist in Geneva, laid 
before the Paris Academic de Medicine his forceps for the extraction 
of the fetal head without danger to the mother or the fetus. The 
rumor that there existed an instrument of this kind was already ex- 
tant and for many years the forceps had been in the possession of 
the Ghamberlen family, but they had kept it a secret, selling the 
forceps wherever they could but not allowing it to be published. 
When Palfyn exhibited his instrument the idea met with general 
disapproval. This came because the knowledge of the condition of 
the pelvis and mechanical phenomena of labor were very limited. 
De la Motte, in speaking of the forceps, says : "That the thing* is as 
impossible as to pass a cable through the eye of a needle, because, 
how can one pass an instrument of steel where one cannot even pass 
a catheter, or a douche point, not even a myrtle leaf, etc." He adds, 
overcome by the great importance of such a discovery, the follow- 
ing damning' judgment on the Ghamberlen family: "If the thing 
is true, as it is false, and also that this man died without rendering 
his instrument public, he deserves that a worm devour his vitals 
throughout all eternity, because of the crime he has committed in not 
giving the means to save the lives of an infinite number of poor 



388 NOTES ON OBSTETRICS—SENIOR CLASS. 

infants who are lost by the absence of such aid," This appHed to 
the Chamberlen family because there had existed with them quite 
a complete forceps for many years. 

The first forceps was invented probably in 1580 or 1590 by Peter 
Chamberlen, the elder, the son of a Huguenot, Wm. Chamberlen, 
who fled from Paris in 1569 and settled in Southampton. In 1670 
one of the large family went to Paris to sell the instrument for 
$7,500.00. Mauriceau, to test the value of Qiamberlen's pretenses, 
suggested that the latter attempt the delivery of a woman with ex- 
treme contraction of the pelvis, upon whom he had previously de- 
cided to perform Caesarean section. Chamberlen declared that 
nothing could be easier, and at once, in a private room, set about the 
task. After three hours of vain effort, he was obliged to acknowl- 
edge his defeat. The Avoman died from injury to the uterus, the ne- 
gotiations for the sale were dropped, and Chamberlen returned with 
his secret unrevealed to England. Later he sold the secret to a Roon- 
huysen, in Amsterdam, who sold it in turn to any doctor having the 
necessary large amount of money — but sold only half the forceps, 
adding fraud to infamy. A student in the home of Roonhuysen had 
a chance to see the forceps when the former was absent, gave a 
picture of it to a friend who published it. But Palfyn's forceps, and 
many improvements, made this hardly necessary. 

Palfyn's instrument was a heavy one, consisting of two curved 
parallel spoons, with heavy wooden handles, tied together with 
tapes. 

Other obstetricians improved them by crossing the blades and 
lengthening- them, giving them also a better shape. In England 
Smellie improved the forceps, but retained the short form and put 
on the English lock. Up to 1880 there were over 200 different for- 
ceps. Now probably over 500. If ever you think of inventing a new 
forceps, first consult Kilian's Armamentarium lucinae. 

DcHnition — The forceps of obstetrics is an instrument designed 
to extract the fetus by the head, from the maternal passages, without 
injury to it or to the mother. As soon as the right of either is en- 
croached upon, the instrument ceases to be the forceps of obstetrics, 
but simply an instrument of extraction, similar to the craniotomy 
forceps, and not as good. 

Description — Consists of two blades, "right" and "left," and 
they are named from that part which goes in the pelvis. Each blade 
has a handle and a hook-like projection; curved on the flat — the 
cephalic curve ; curved on the edge — the pelvic curve. Fenestrated 
to give lightness and better hold on the head. Placed together the 
forceps is made by crossing at the lock. This consists of a shoulder- 
like projection of the blade which is covered by a flange on the other 
blade. The Simpson is the one adopted by the Vienna school. Is. 



' NOTES ON OBSTETRICS— SENIOR CEASS. 389 

therefore, sometimes known as the Menna School Forceps. Meas- 
nrements : 

Length 35 cm. 

Handles 15 cm. 

Cephalic curve 8 cm. 

Pelvic curve 7^ cm. 

Distance between tips 2^ cm. 

Fenestra 1 1x4^ cm. 

There is a distance between the shafts of the blades big enough 
to put the finger in. The cephalic curve of the Simpson forceps is 
large, and, therefore, there is little danger to the fetal head from 
compression. Some forceps, especially the German, have a mur- 
derous cephalic curve. The forceps should feather a little. Steel, 
welded steel throughout — edges well rounded. Hollow handles, 
well nickeled, not heavier than i^ pounds. The front of the for- 
ceps is the concavity, the side on which the lock is, and to which the 
tips point. The forceps lies in the right oblique, left oblique, trans- 
verse diameter, etc., when a line drawn through the fenestrae lies 
in one or the other diamieter. For example, we say the forceps lies 
in the right oblique diameter of the pelvis when a line drawn 
through the center of the fenestrae lies in this diameter. The front 
of the forceps a'nd the tips will point to the right side. 

When we speak of right, left, front, back, upper, lower, we al- 
w^ays refer to these directions on the mother. If we wish to indicate 
them on the fetus it must be specifically so stated. 

The Functions of the Forceps — Simply mechanical. The forceps 
does irritate the lower uterine segment and sometimes evokes 
strong p'^ins. This was considered by some as the main function 
and called the "Dynamic Action" of the forceps. This is not con- 
stant, and of little importance. 

Nor is the forceps an instrument of compression. Experimen- 
tally proven that the volume of the head cannot be reduced more 
than a few cubic mm. without great danger to the child. Pressure in 
one diameter causes a bulging out in the others. A certain amount 
of compression is inevitable, but v/e seek to avoid it as much as pos- 
sible. You must not hope by compression of the head to bring it 
through a narrow pelvis alive. 

The forceps is not an instrument to alter the position of the head 
in the pelvis, e. g., to change an occipito-posterior to an occipito- 
anterior position. It may, however, be used to aid rotation during 
the tractions, and thus imitate the natural mechanism. 

The forceps is not an instrument to be used as a lever or a 
twister, i. e., pendulum motions and twisting are not allowed, be- 
cause then the fulcrum is part of the mother and she is dangerously 
bruised and torn. These motions are not observed in nature. 



390 NOTES ON OBSTETRICS—SENIOR CEASS. 

The function, then, of the forceps is simply one of traction, sta- 
tionary traction. It suppUes, from below, a lack of force from above, 
and only when used as such an instrument will it remain harmless. 

Conditions for Forceps Operation — 

(i) Head must be engaged — 

If the head is still movable above the inlet there are better oper- 
ations than forceps, i.e., prophylactic version. How to tell when 
the head is engaged : 

(a) When lowest part of the head reaches a line between 

the spines of the ischii it is engaged. Span the spines 
with the fingers and estimate. 

(b) By the covering of the sacrum. Two-thirds must be 

covered by the head. 

(c) By the covering of the symphysis ; three-fourths must 

be covered (not very good). 
In some cases the head may be fixed in the inlet ; if indications 
arise a cautious trial of the forceps is here allowable. 

(2) The pelvis must not be too small, nor the head too large. 
In contracted pelves in which the conjugata vera is less than 8^ cm. 
it is not safe to use forceps. The pelvic outlet must not be too small. 
If the baby is hydrocephalic, no forceps, because the blades will 
generally slip oiT, nor must the head be too small. No forceps to 
small heads or after perforation. Use a small forceps if necessary 
for a premature infant. 

(3) Bag of waters must be ruptured and membranes out of the 
way — danger of dislocation of the placenta, causing asphyxia of 
child and hemorrhage. 

(4) Cervix must be efifaced and os dilated ; or it must be posi- 
tively and easily dilatable. 

Reasons — ^(a) May tear the cervix, which may extend into the 
abdominal cavity — peritonitis or immediate hemorrhage, (b) May 
grasp the cervix in the forceps and crush or tear it off. (c) It pulls 
the uterus down, stretching or tearing its pelvic attachments, caus- 
ing later prolapse, etc. (d) It pulls the bladder down, stretching or 
tearing its pelvic attachments, causing later incontinence or dysuria, 
etc. 

(5) Child must be living — 

If dead, craniotomy. If in doubt, forceps always. , 

Indications for the Forceps Operation — 

In general, the indications have already been given under ex- 
traction. They are the same, since extracting by the breech is not 
different from extraction by the head, except that in the latter we 
cannot take hold of the fetus directly with the hands, but must 
use a pair of forceps. Will now mention the indications approxi- 
mately in the order of frequency : 



NOTES ON OBSTETRICS—SENIOR CLASS. 391 

(i) InsitiTiciency of the expulsive pozcers of labor: These cases 
form 75% of the forceps operations in America. Head has come 
down to the perineum, has perhaps rotated anteriorly and become 
visible during the pains, but the patient is exhausted, does not press 
down, and the uterine contractions are feeble. The head may be a 
little large or the perineum a little more resistant than usual. These 
are cases of relative insufficiency of the powers of labor. A caput 
succedaneum begins to form on the head and the child's life becomes 
endang-ered from asphyxia. In regard to the time to operate con- 
sider — 

(i) The size of the caput succedaneum. 

(2) The fetal heart tones. 

(3) The condition of the woman. Must operate before she is 

too much exhausted. 

(4) An arbitrary limit of 2^ to 3 hours after complete dila- 

tation and the head has come onto the perineum. 
In these cases the signs are : 

(a) Asphyxia; rapid or very slow heart tones; liquor amnii 

stained with meconium and violent movements of the 
fetus. These give the indication for terminating the 
labor. 

(b) Signs of danger on the part of the mother from pro- 

longed labor; exhaustion; threatened rupture of the 
uterus, etc. 

(2) Deep transverse arrest: When the occiput, owing to the 
head being deflexed, or something else, does not rotate anteriorly. 
Sagittal suture lies in the transverse diameter of the pelvis, small 
fontanelle on one side, usually the right, large on the other, both on 
the same level, nearly. Labor comes to a standstill. Military attitude 
of fetus. Child has head set squarely on shoulders in a position 
median between face and occipital. 

(3) Complications in Labor: 

a. Eclampsia. 

b. Fever ; infection during labor ; endometritis septica ; tym- 

pani uteri. 

c. Acute diseases, e. g., pneumonia. 

d. Chronic diseases : tuberculosis ; emphysema ; heart disease, 

causing too much work on the heart, or edema pul- 
monum. 

e. Hernia, especially if incarcerated. 

f. Placenta previa, certain cases. 

g. Premature detachment of placenta. 
h. Prolapse of. the cord. 

Not by any means all the indications, but they are the most 
common. 



392 NOTES ON OBSTETRICS—SENIOR CLASS. 

(4) Face and Brow Presentation : Per se, they do not give the 
indication for forceps, but above indications more likely to be present. 

(5) Contracted Pelvis: Very seldom an indication for forceps 
here. When the head is movable above the pelvis, not proper to use 
the forceps ; better operation is prophylactic version, or you must 
wait till the head is engaged. Never use the forceps to draw the 
head into the pelvis nor to dilate the cervix. If the head has gotten 
past the inlet in a flat pelvis, usually there is no indication for the 
forceps, since the labor usually terminates quickly. But in a gen- 
erally contracted pelvis labor may have to be terminated by the for- 
ceps. Wait till the head is well moulded, and remember, great care 
is necessary since there is much danger of bruising and tearing the 
soft parts, even rupturing the pelvic joints. 

VI. Finally — Forceps may, very exceptionally, be used on the 
after-coming head. May also be applied to the breech if the baby is 
dead; no objections to the use of the breech forceps or the blunt 
hook on the breech of a dead baby. Thus, you see, that indications 
must be covered by conditions. The indications may be present but 
the conditions absent, e. g., the fetus may be in danger of asphyxia 
but the cervix not dilated ; the mother may have eclampsia but the 
cervix not dilated, etc. 

Preparations for the Operation — Same as for a version, or any 
obstetrical operation. 

a. Disinfection, — subjective and objective. 

b. Transverse position in bed. Better the kitchen table. 

c. Rectum and bladder empty. 

d. Anesthetic, — almost always in primiparae, not actually neces- 
sary in multiparae, but is usually given. 

e. Accurate diagnosis of presentation and position, confirmed just 
before operating. 

f. Have everything ready for asphyxia neonatorum and post 
partum hemorrhage. 

g. Room properly ordered, good light, plenty tables, etc. See 
''Obstetrics for Nurses," page 165. 

Forceps operation bloodiest of obstetrics. Never an operation 
of convenience. In primiparae vagina usually bruised and torn, cer- 
vix sometimes in shreds, or even torn from the vagina. 

We will consider the usual forceps operation. Head at the out- 
let of the pelvis, rotation being nearly complete or completed, the 
so-called, 

LOW FORCEPS OPERATION. 

Rule — The front of the forceps must point in the direction of the 
point of direction. 

There are four stages to the operation : 



NOTES ON OBSTETRICS—SENIOR CLASS. 393 

First Act — Application of the Blades. Second Act — Adaptation. 
Third Act — Extraction. Fourth Act — Removal. 

First Act — Application of the Blades — 

There are two blades to the forceps : left, right. The left blade 
is the one that lies in the left side of the mother. It is always 
grasped by the left hand and is always passed first. The right is 
that blade which lies in the right side of the mother, and is always 
held in the right hand. 

Left Blade First — Two fingers of the right hand are passed into 
the vulva, vagina and, if the cervix is felt, into the cervix, and in- 
side the membranes. Nothing must intervene between the forceps 
and the head of the child. To be certain of this the fingers are 
passed alongside the head and the forceps inserted between the head 
and the fingers. The fingers are passed as high up as possible, and 
the tip of the forceps must be gxiarded as long as possible, being sure 
that the tip passes inside the cervix. The thumb of the hand guides 
and presses the blade in. When the fenestra of the blade goes 
inside the vulva, time is come to sink the handles. When the lock 
has come near the perineum the first half of this act is completed. 
If properly done the blade falls into place almost of its own weight. 

There are three methods of grasping the forceps : 

(i) Like a pen. (2) Like a scalpel. (3) Like an amputat- 
ing knife. 

During the first part of the act like a pen, then like a scalpel, 
passed with the carefulness of a sound. Third method is not good, 
is clumsy and harmful. After introduction of the blade, examine 
to see if it lies properly. 

Now pass the right blade. Reason of this is because the lock 
is on top of the forceps and if the right is passed first the left 
will cross on top of the right, and then one would have to uncross 
the forceps, while the blades are inside, wdth danger of mutilating 
the maternal soft parts. Same rules to be observed. In locking, 
remember the rule that the "front" of the forceps points in the di- 
rection of the small fontanelle. Now listen for the heart tones. 
Press the handles together while listening. If the tones get weaker 
and slower it indicates that the cord is probably compressed by the 
tips of the blades. 

Second Act — Adaptation of the blades or locking — 

In the operation under consideration, — low forceps, — the small 
fontanelle has already rotated anteriorly and the blades of the for- 
ceps, after being applied, fit naturally to the sides of the head. If 
the small fontanelle should not have completely rotated, or if the 
blades do not lie in a position so that they can be locked, they must 
be brought into position for locking ; this is called adaptation, or 
locking. 



594 NOTES ON OBSTETRICS—SENIOR CLASS. 

Before attempting this maneuver be sure that there is no maternal 
tissue in the blades. The simplest method to bring the blades into 
position is : 

(i) To press the handles down toward the perineum, gently but 
firmly. If not successful : 

(2) Press them down, twisting them gently by means of the 
hooks on the handles. Not too much force. 

(3) Press the handles down, push them into the pelvis, and 
tw^ist, all at the same movement. This movement should succeed 
easily. But if it does not, do not persist because you will tear the 
cervix or vagina, and there is almost always some obstacle to the 
locking which must be recognized and removed. 

(4) Remove the forceps and re-apply the blades. Examine to 
see if you have not made some mistake in the diagnosis. Perhaps 
there is hydrocephalus. 

After locking, listen to the fetal heart tones. Examine to see if 
the cervix or hand, or cord, is caught in the grasp of the instru- 
ment. 

Third Act — Extraction — 

If the forceps lies properly the handles will point in the direction 
in which to make traction. After locking the forceps, make one 
gentle traction to see if the blades lie properly. This is called the 
'Trial Traction." Four points to remember — 

(i) Always pull during a pain. If there are none, massage the 
uterus ; if none then imitate the pain by making the traction grad- 
ual at first, slowly reaching an acme, and then slow relaxation. 

(2) Power to use : Use as little as is necessary. Regulate power 
hy the advance of the head. Never over 60 pounds. Disregard time, 
"but watch the fetal heart tones. 

(3) Stationary traction. No corkscrew movements or pendulum 
movements, because; ist, unnecessary; 2nd, are not physiological; 
3rd, always grave risks to maternal tissues. 

(4) Pull in the axis of the pelvis. 

After the trial traction, grasp the forceps in both hands, the 
right on the lock, the left on the handles, thumbs underneath, el- 
bows at the sides, seated before the patient. One even, slow, grad- 
ually increasing traction, in the horizontal plane, or a little down- 
ward from this. Watch to see if any progress, sometimes can 
feel a sudden advancement of the head. If not, the forceps goes 
"back and you can feel that no progress has been made. Wait a 
few minutes, count the heart tones, loosen the forceps ; now a second 
traction, slow, stronger than the other. Examine for the position 
of the small fontanelie. If it was a little to one side, may find it 
now rotated toward the median line. Wait for some pains, since 
they may give the head a better position or cause marked progress. 



NOTES ON OBSTETRICS—SENIOR CLASS. 895 

When the head has begun to bulge the perineum, go more carefully. 
Pull straight out till the occiput is well under the pubis. When 
this is so, pull upward at an angle of 60 degrees from the horizontal. 
Watch the perineum, control the fetal heart tones, if they are all 
right, no need to hurry, but protect the perineum. Principles are : 
(i) Slow delivery. 

(2) Give the best diameters to the outlet. 

(3) In hard cases may take off the forceps and express the head 
by Ritgen's method (pressure from the rectum), or from the peri- 
neum. 

(4) In primiparae do episiotomy. Do not put the hand on the 
perineum, because you cannot see it tear and you may get the hand 
infected with feces. To accomplish these things, stand ofif to the left 
side of the patient, if you are right-handed ; to the right side if left- 
handed ; grasp the forceps with the right hand, about the lock, the lit- 
tle finger between the blades, and gently, slowly, line by line, flex 
the forceps over on the abdomen, turning the head out ; at the 
same time pull the head up vertically to keep the nape applied 
to the under surface of the pubis. Same principles as when the 
head is being delivered normally. Bring the same diameters 
through. 

Fourth Act — Removal — 

Unlock the blades and let the head fall into other hand (keep 
the forceps clean, perhaps there are twins). In removing the 
forceps while head is still in the vulva, reverse the motion of ap- 
pHcation, being careful not to injure the child. Attend to the eyes 
and mouth as usual. Extraction of the body on general principles, 
but better, if possible, to leave the expulsion to the mother, as gen- 
erally she is just awakening from the chloroform. Careful of the 
perineum with the shoulders. 

FORCEPS IN THE UNUSUAL MECHANISMS OF OCCIPI- 
TAL PRESENTATION. 

I. Deep Transverse Arrest — In some cases where a delay in 
labor has been manifest for some time, an examination reveals the 
head well down in the pelvis, the sagittal suture in the transverse 
diameter, the small fontanelle to one side, generally the right, the 
large fontanelle to the other side, and both on the same level. This 
condition is called, "Deep transverse arrest" — sometimes "Impac- 
tion," — between tuberosities ischii, — and is caused by: ist, a fiat 
pelvis ; 2nd, weakness of the powers of labor ; 3rd, pendulous abdo- 
men ; 4th, dolicocephalu-s. Left to itself the condition ends by — 

(a) Final rotatiorLof the occiput forward, flexion taking place, 
then case is normal. 



396 NOTES OX OBSTETRICS—SENIOR CLASS. 

(b) The head may appear in the transverse diameter. This re- 
quires strong pains, small child, large pelvis. 

(c) The occiput may rotate into the hollow of the sacrum, the 
head remaining flexed, or the forehead comes down, the head extend- 
ing. These are forehead presentations. 

Treatment — Keep the woman on that side to which the occiput 
points for a long time. Wait for a long time, as the occiput will 
rotate to the front in nearly all cases. If it does not after waiting 
2^ hours, after complete dilatation of the cervix, may try to aid 
rotation by the maneuvers described under occipito posterior posi- 
tions. Failing all these, the forceps. 

Operation — We have two objects in view : first, we must complete 
the rotation ; second, we must extract. It has been recommended to 
turn the head directly with the forceps, but this is bad practice, 
because if the vaginal walls lie fast to the head they will turn with 
it and be torn from their attachments. Extraction and rotation 
are accomplished together. Never turn the head without making, at 
the same time, traction. More traction than rotation always. 

First Act — Application of the blades — 

It is the rule to apply the blades to the sides of the head. In 
this case they would have to lie in the antero-posterior diameter of 
the pelvis. The Simpson forceps is not adapted to this, because of 
the pelvic curve. Some French forceps, with very narrow blades, 
may be thus applied. The blades should not be applied in the long 
antero-posterior diameter of the head, since. then one blade would 
be over the face and the other over the neck. The blades are ap- 
plied in the oblique diameter of the pelvis. 

Rule — The front of the forceps must point to that side of the 
pelvis in which the point of direction lies. If the occiput is to the 
left, the front of the forceps must point to the left side of the pelvis, 
and the forceps is placed so that when rotation is complete the 
pelvic curve will correspond to the curve of the pelvis. When 
the small fontanelle is to the right side, the forceps is applied in the 
right oblique ; when the small fontanelle is to the left side, forceps 
is applied in the left oblique diameter of the pelvis. When we say 
that the forceps lies in an oblique diameter, it means that the line 
between the blades lies in the oblique. There are two ways of pass- 
ing the blades : — 

One is to pass them directly into the diameter in which you desire 
them. 

The other, to pass them into the back part of the pelvis, one to 
each side, and then adapt them to the head in the proper diameter. 
The first requires greater skill and good knowledge of position. The 
latter is generally practiced. 

Let us take Deep Transverse Arrest in Right Occipital Position — 



NOTES OX OBSTETRICS—SEXIOR CLASS. 397 

Left blade in left hand, passed to the left side. Pass it into the 
region of left sacro-iliac joint. Right blade passed, likewise, to the 
region of the right sacro-iliac joint. The first blade is adapted be- 
fore the second is passed. 

Adaptation or Locking — Left blade is Hfted to the right side, and 
the two fingers inside pull the blade around the pelvis toward the 
pubis till it passes by the face and comes to rest near the left 
ilio-pubic tubercle. 5sOw the right blade is passed and pushed 
in the same manner to the side of the head. The forceps now lies 
in the right oblique and the point of the forceps looks to the same 
side as the point of direction. Right blade lies on the posterior parie- 
tal protuberance ; the left, on the anterior malar bone. Difficulty 
in locking is overcome in the same manner as given before, — press 
them down toward the perineum somewhat and twist slightly by 
means of the hooks. 

Extraction and Rotation — Make one gentle traction downward 
and forward. This is to see if rotation will not take place inside 
the forceps, which not seldom occurs. If there is no tendency for 
this, a second traction, accompanied by slight rotation, so as to bring 
the occiput to the front, i. e., from right to left. If some rotation 
has taken place, open the blades and let them rest now at the sides 
of the head. Make gentle tractions and rotation which must be 
simultaneous, disregarding time, if fetal heart tones are good. 

After rotation has occurred may take oft" the forceps and leave 
the case to nature. If the pains are strong, you can see that further 
traction is superfluous. When the small fontanelle has come to the 
front, the operation is exactly the same as has been described. 

At first the handles of the forceps will not come together and 
must not be forced. This is because the head is not grasped from 
side to side, but from forehead to occiput. After rotation has oc- 
curred, the handles come together. IMake frequent examinations 
to see how far the small fontanelle has rotated. 

Occipito Posterior Position — These are too .much dreaded by 
physicians. The large majority terminate spontaneously and favor- 
ably for both. Head enters the pelvis late, dilatation and effacement 
are not so rapid or complete. Pains are nagging and irregular. 
Labor tedious, may last a day or more. Bag of w^aters ruptures 
early. Head in coming down pushes the tissues in posterior part 
of the pelvis before it so that the perineum bulges early. Flexion 
of the head is late. Head almost always rotates to the transverse 
diameter, and then the forceps may easily, terminate labor. 

Treatment — The treatment, therefore, is one of watchful ex- 
pectancy, till some indication arises to interfere. \"arious maneuvers 
have been tried to favor anterior rotation — 

( I ) Keep the woman on that side to which the occiput points. 



398 NOTES ON OBSTETRICS—SENIOR CLASS. 

(2) Hodge's plan, — During a pain, with two fingers, press upon: 
the sinciput, flexion results and rotation is facilitated. 

(3) Tarnier's plan, — Pass two fingers behind the ear of the 
baby, the other hand pushes on the forehead outside, while the two 
fingers pull the occiput forward. 

(4) Failing in this, the half-hand may try the same maneuver, 
but where these succeed the case would perhaps have terminated it- 
self. 

(5) Author's method, — A combination of internal and external 
manipulations. Flex the head from below, then pull the occiput for- 
ward, both maneuvers with the hand in the vagina. From the abdo- 
men first dislodge the shoulder by extending the child's body ; then 
pull the breech down, so as to flex the axis of the fetus strongly ; 
then pull the shoulder to the front by operating on the back. Hold 
what you have gained and repeat the manipulation if necessary. If 
the head, as is not uncommon, can be pushed up so as to allow the 
inside hand past the promontory to reach the shoulder, the fingers 
may swing the child's trunk around, so as to bring the back anterior. 
Now the occiput will remain anterior. CARE ! 

(6) It is not justifiable to rotate the head through an arc greater 
than one-fourth of a circle by means of the forceps, because the 
danger of laceration of the mother's soft parts is too great. 

The operation of the forceps is very difficult and varies with 
the position of the occiput. When the occ^ut is in a position be- 
tween the transverse diameter and the hollow of the sacrum, the 
forceps is applied in the transverse diameter of the pelvis and 
traction made in the horizontal plane, no attempt at rotation being 
practiced. If the occiput comes down, flexion is increased, and some 
anterior rotation occurs. If this is noticed the forceps is opened 
and re-applied. If, on the contrary, the occiput should show a 
tendency to rotate posteriorly, no attempt should be made to hinder 
this. To force the rotation into an anterior position would seldom 
succeed, and there is great danger of tearing the soft parts. Pull 
the head well into the pelvis before you try to aid rotation. 

When the occiput is directed behind, i. e., in cases of posterior 
rotation of the occiput, the head must be delivered in flexion, if this 
is possible. 

Forceps applied, as usual, but the concavity of the forceps, the 
"front," looks to the forehead, which from now becomes the "point 
of direction." Traction on the parietal bosses, a little upward from 
the horizontal plane. This causes flexion and it has happened that 
anterior rotation occurred even now. Deliver the occiput first. 
The forehead rests behind the pubis till the occiput is delivered over 
the perineum, then forehead, face and chin come under the pubis. 
Great danger of rupture of the perineum, therefore, episiotomy al- 



NOTES ON OBSTETRICS—SENIOR CLASS. 399' 

ways in primiparae and in multiparae, if the perineum well pre- 
served. Scanzoni's method of forceps seldom needed. 

Forceps in Face Prescniation — Face presentation is eutocia and 
almost always terminates spontaneously. Remember that : 

(i) It requires much more patience. 

(2) First stage is slower, second stage lasts seven hours. 

(3) Anterior rotation of the chin takes a very long time. 

(4) The- head seems engaged long before the bi-parietal diam- 
eter has passed the inlet, owing to the length of the wedge. 

(5) That the face does not rotate till it is well down, on the 
perineum. 

(6) That the chin must come to the front for labor to be com- 
pleted. True of almost all cases in spontaneous labor, invariably 
for forceps cases. 

Indications — Face presentation per se is no indication. Same 
indications as for extraction and forceps in general. But the in- 
dication must be stricter, especially the length of the labor. In- 
sist on the conditions. 

Conditions — Beside the usual conditions — 

(i) Head engaged. 

(2) Cervix dilated. 

(3) No disproportion between head and pelvis. 

(4) Bag of waters ruptured. 

(5) Child living, — one new condition: 

(6) The chin must not be behind the transverse diameter of the 
pelvis. 

Preparations — Same as for ordinary forceps, but place the crani- 
otomy instruments on to boil, in addition to the ordinary forceps. 

Treatment — In the treatment of a case of face presentation, pre- 
serve the integrity of the bag of waters. Let woman lie for some 
hours on the side to which the chin points, and do not operate till 
the chin has rotated into, preferably, beyond the transverse diam- 
eter. Wait a long time because if the chin does not come to the 
front, craniotomy is almost the only alternative. 

Operation — First, when the chin has rotated. 
(I) Same application as in vertex. 
(II) Adaptation different. Instead of depressing the handles, 
must raise them to, or above, the horizontal plane. This is to sink 
the blades into the hollow of the sacrum so as to bring them over 
the parietal bosses. If the blades are placed over the front, they 
will slip off from the narrow brow and neck ; therefore, raise the 
handles, lock and then sink the handles. 

(Ill) Traction much more carefully. First downw^ard so as to 
deflex the chin. Traction in the horizontal plane till the chin is 
well out from the symphysis then upward, but not so acutely, over 



400 NOTES ON OBSTETRICS—SENIOR CLASS. 

the symphysis, as in vertex presentation. In primiparae, usually 
do episiotomy. 

Operation — Second, when the chin is not fully rotated — 
Delay operation as long as possible, because it is much harder, 
more delicate, and there is much greater liability to do injury to 
the mother and bring a dead child. If the child is dead, no forceps 
but craniotomy. In cases of doubt, give the child the benefit of the 
doubt. 

(i) Application — Same as usual, but the blade that comes in 
the side where the face is, must be placed directly in position, because 
it must not pass over the face and neck in rotating it into place. 

(2) Adaptation' — Blades placed in an oblique angle to the facial 
line, i.' e., in mento-dextro transverse, in right oblique, left blade 
to the front, right blade behind. See the danger, — face grasped from 
the chin to the forehead, compression of the neck ; therefore, still 
births common. 

Rule — Front of the forceps in direction of the point of direction 
(i. e., the chin). 

(3) Extraction and Rotation — To be accomplished very slowly 
and gently. Unlock forceps frequently. Same principles as in deep 
transverse arrest of the occiput. Extract and rotate at the same 
time. Slowly. 

B?'ow Presentation — Same rules as in face presentation opera- 
tions. Here the brow must come to the front and appear in the 
vulva. Then bring the occiput over the perineum, and finally de- 
press the handles to bring the face and chin from behind the pubis. 
Episiotomy in primiparae. 

HIGH FORCEPS OPERATION. 

Thus far we have considered forceps when the head was in the 
outlet, or at least, below the mid-plane. When the head has just 
passed the inlet it may become necessary to apply the forceps. On 
certain occasions there is some indication for forceps when the head 
is in the inlet, the bi-parietal diameter not having quite passed this 
plane. Here the head is so well fixed that it may be impos- 
sible to move it away to do a version, and yet it is not quite engaged 
so as to fulfil the condition for forceps. Under these circumstances 
the forceps is an instrument of trial, or, as Carl Braun said, "an 
instrument of diagnosis." We want to see if the head will come into 
the pelvis. If, after suitable trial, the head will not come in, must 
do a craniotomy, even if the child be alive. 

Up to 1892 the mortality of the high forceps operation was 15%, 
but now, because of better selection of the cases and the making of 
stricter indications, the percentage is lower. 



NOTES ON OBSTETRICS—SENIOR CLASS. 401 

For this operation a special forceps is advised, the Axis Traction 
Forceps, i. e.. one that will allow traction in the axis of the inlet. 

The head, when high up, has a curve to traverse. Owing to 
the sacrum and perineum, traction cannot be applied in the axis of 
the inlet. If applied in any other line, the problem is like trying to 
pull an object around a corner, either the corner or the object suf- 
fers. Therefore, we want some instrument which will draw in a di- 
rection of the inlet's axis. Simplest would be a forceps shaped like 
the letter S. We have such instruments, but they are not very 
useful, because the head must have freedom to move the way it is 
forced by the factors of the mechanism of labor ; therefore, we must 
have an instrument which will confer some degree of mobility to the 
head. In 1881, Tarnier introduced a forceps which fulfils these 
two conditions: ist, it allows traction in the line of the axis of the 
inlet ; and 2nd, it confers a certain degree of mobility on the head. 
Tarnier has modified his original instrument many times. His latest 
model can hardly be improved upon. 

Indications for High Forceps — 

(i) Head wedged in the inlet, too fast to be pushed up so as to 
do a version, and when you believe a slight pull will help it into the 
pelvis. This arises after a long labor and something indicates in- 
terference. 

(2) Head has just passed the inlet but has not yet reached the 
mid-plane, and some indication arises to terminate labor, e. g., 
eclampsia, exhaustion, asphyxia of child, etc. 

(3) Head not yet engaged, but, version being impossible, from 
one cause or another, high forceps must be tried before craniotomy ; 
given, of course, an indication for delivery. 

Conditions, which must be insisted upon, as the mortality is very 
high at best : 

(i) Head must be engaged, or very near it. Sometimes a large 
caput succedaneum may reach low down in the pelvis and make 
one think the head is really lower than it is. In these cases, push 
finger along the side of the tumor, or try to massage it away. Re- 
member the three criteria of engagement. 

(2) Dilatation must be complete. 

(3) Bag of waters must be ruptured. 

(4) Pelvis not too contracted. In a generally contracted pelvis 
with a conjugata vera less than 8^ cm., almost impossible to bring 
a living child. Even with 9 cm., unless the. child is small; hard oper- 
ation. In the flat pelvis, the limit is 8 cm., conjugata vera. If the 
head is movable, do version. If fixed, forceps, — as a trial. 

Preparation — Same as usual but insist on the table, because the 
operation is always difficult. 



402 NOTES ON OBSTETRICS—SENIOR CLASS. 

Operation — 

(i) Application — Blades to be laid in the sides of the pelvis. 
With the head so high up the forceps must go deep in and then 
curves of forceps and pelvis must correspond. But the head is 
grasped in the antero-posterior diameter, since the head, when en- 
tering the pelvis, especially if it be a flat pelvis, comes in with 
the long axis of the head in the transverse diameter of the pelvis. 
This cannot be avoided, but to prevent serious compression of the 
head, do not press the handles of the forceps together, place the 
finger between the handles. Pass the half-hand high up inside the 
cervix and membranes. After blades are in position they are simply 
locked without any attempt at rotation, etc. 

(2) Adaptation — Same rules as usual, — sink the forceps on the 
perineum, sink and twist, sink, push in and twist. These maneuvers 
are especially necessary here. Bring the handles as near to the 
perineum as possible. The blades may be felt from the outside and 
adaptation thus aided. 

(3) Extraction — Same rules here as in ordinary forceps, — trac- 
tion, intermittent, stationary, not to exceed 60 lbs., and with pains. 
Make eight tractions, if no palpable progress, remove the forceps 
and perform craniotomy, even if the child be living, or do sym- 
physiotomy, if the condition of both patients is good. Traction first 
downward. If no progress, put the patient in the hanging or 
Walcher posture. Not justifiable to make more than eight powerful 
tractions, because of danger of cervico- and vesico-vaginal fistula. 

If the head comes down into the pelvis there is a certain move- 
ment which is unmistakable. You may now remove the forceps, 
or loosen them. Rotation of the occiput to the front may now occur. 
If you see it occurring leave the forceps alone, so as not to inter- 
fere with the motion. After it has occurred, may take out the forceps 
and leave the case to nature, or terminate the labor with the axis 
traction forceps, or with ordinary forceps (Simpson). 

Pi'o gnosis of the Forceps Operation — This operation is one of 
the bloodiest in all obstetrics. Some tears of the passages are in- 
evitable and these increase in number and severity the higher up the 
forceps is done; therefore, the most in high forceps operations. 

In the high operations, the cervix may be torn, especially if the 
condition relating to the cervix is not fulfilled. If rotary motions 
with the forceps are made, the vagina may be twisted from its con- 
nective tissue attachments, or the cervix may be caught in the grasp 
of the forceps and be bruised or torn off bodily ; or the operator, 
thinking the blade is inside the cervix, may use force, and as the 
tip of the instrument is in the fornix, he may punch through this up 
under or through the peritoneum. 

The vagina itself may be torn or cut by the blades of the for- 



NOTES ON OBSTETRICS—SENIOR CLASS. 403 

ceps, and the vulva also, especially when the forceps blades are bent 
upward in the delivery of the head, the edge may cut the crura of the 
clitoris and cause severe hemorrhage, or pressure necrosis which 
may go to the bone. In severe forceps operations the symphysis 
pubis has been ruptured, also the sacro-iliac articulations. 

Vesico-vaginal fistula from compression of the bladder, or tear- 
ing by the blades. Perineal tears to and through the rectum. Hema- 
toma vulvae. 

Post-partuiu Hemorrhage — i. Atony uteri. 2. Cervix tears. 
To these are added the dangers of the slipping of the forceps. This 
happens in two ways, according to Mme. La Chapelle ; in the hori- 
zontal sense, i. e., the forceps slide off in the direction of the line of 
traction ; and in the vertical sense, i. e., the forceps slip off in a line 
perpendicular to the line of traction. 

Causes — 

(i) Head grasped too low down (think head engaged). 

(2) Forceps feather too much. 

(3) Do not compress enough. 

(4) Head too small or too large, or not grasped properly, c. g., 
when forceps lie over the neck. 

(5) When the head is at the outlet and you bend the handles up 
too soon. 

The dangers of the slipping are great, especially laceration of the 
soft parts and injury to the head of the fetus. 

You diagnose the slipping from the sensation of elastic resistance 
and seeing the handles tend to separate. If the forceps has slipped, 
can feel the sudden loss of resistance and may hear a snapping noise. 

When the forceps slip in the horizontal, can feel the forceps come, 
but there is no feeling that the head moves. 

The forceps slip off more easily when the head is at the inlet, 
since, in the pelvis, the sides of the pelvis hold the forceps applied 
to the head. You must recognize the slipping early. 

Treatment — Take off the forceps and re-apply. If too small 
head, get a smaller forceps. If hydrocephalus, puncture the head. 

Dangers of Forceps for the Fetus Are — 

(i) Compression of the head, slowing of the heart, asphyxia. 

(2) Fracture of the skull, with or without subdural hemorrhage. 

(3) Hemorrhage from, rupture of the sinuses at the base. 

(4) Crushing of the orbital plates, of the face, eyes, etc. 

(5) Facial paralysis, from compression of the nerve as it comes 
out in front of the mastoid. Usually good prognosis. 

(6) Pressure necrosis of the scalp, perhaps to the bone. 

(7) Said that idiocy more frequent after forceps. 

(8) Cephalhematoma. Usually good prognosis. 



404 NOTES ON OBSTETRICS—SENIOR CLASS. 

(9) Compression of the cord which is around the neck, and 
asphyxia. 

Forceps operation has a higher death rate than normal labor; 
8% for high forceps, for the child 15% to 20%. The forceps opera- 
tion is never one of convenience, always one of necessity. Never 
operate to save mother pain, or to save your time, or to satisfy the 
clamor of her friends. 

OPERATIONS CALCULATED TO CHANGE THE POSI- 
TION OF THE FETUS, OR ITS POSTURE. 

Version — Version may be defined as the changing of a pathologic 
or relatively pathologic position of the fetus into a normal, or rela- 
tively normal position. The definition includes : 

(i) Version from a transverse to a longitudinal presentation, 
either podalic or cephalic. 

(2) Version from a cephalic to a podalic presentation. * 

(3) Version from a podalic to a cephalic presentation. 

The first is always indicated, i. e., all cases of transverse presenta- 
tion give an absolute indication for version. The others need spe- 
cial indications and conditions. These two terms may well be again 
defined as will use them so frequently. 

An Indication — Is a state of affairs showing the need of a cer- 
tain method of treatment, or interference. This treatment may be 
"watchful expectancy" or active operation. 

Examples — Transverse presentation is an indication for version. 
Edema pulmonum, in the second stage of labor, for forceps. 

A Condition is a state of affairs which governs the indication. It 
is a pre-requisite for the carrying out of any line of treatment. 
Sometimes this may be a contra-indication, other times it may be 
something that must be present or absent in order that the operation 
may be done. 

"Contra-indication" does not embrace all that "condition" does, 
while many conditions are really contra-indications. Examples of 
conditions are : In the transverse presentation a condition for version 
is that the uterus be not too contracted. In the forceps case, — 
the cervix must be dilated. A contra-indication to either operation 
is a too highly contracted pelvis. 

Version in Transverse Presentation — We call transverse presenta- 
tion all cases in which the long axis of the fetus crosses the long axis 
of the mother. A crossing at a right angle almost never occurs, 
as the head or the breech and, therefore, the shoulder lies over the 
inlet. We speak of shoulder presentation, — but the back may pre- 
sent, the side, or the abdomen. Transverse presentation is a little 
more frequent than face presentation, — 7/10 of 1%. 



NOTES ON OBSTETRICS—SENIOR CLASS. 405 

Note — For an exposition of the causes, mechanism, prognosis 
and diagnosis of transverse presentation, see third year notes, page 
ooo. 

Treafnient — If you recognize the abnormal position during preg- 
nancy. Version by posture. If persists for two weeks, external 
manipulation and a binder with pads to hold the child in the cor- 
rected position. 

During labor version can be accomplished in three ways — 

(i) By posture. 

(2) By external manipulation. 

(3) By combined external and internal manipulation. 
Posture is useful only for cephalic version or to help either 

of the other forms of version. It is useful in the treatment of trans- 
verse presentation during pregnancy, and the first stage of labor, 
when it is often successful in changing the presentation. Put th^ 
patient on that side to which the head points. The breech then falls 
over to the side and the head goes down over the inlet. After this 
has been accomplished, retain in place by a well padded binder. Suc- 
cess not constant. 

Cephalic Version in Transverse Presentation — In cases of trans- 
verse presentation, the indication lies in the production of a presenta- 
tion that is most favorable to mother and child. Unquestionably this 
is the cephalic presentation, and we should do it when the following 
conditions are present : 

(i) There should be no immediate or prospective indication for 
the rapid termination of labor. 

(2) There must not be the least pelvic contraction. 

(3) The fetus must be very freely movable; bag of waters in- 
tact ; no pains or weak pains. 

1. We gain little by version by the head if there is some indi- 

cation to terminate labor, as we cannot do it, the head 
being high up and forceps not allowed. 

2. If there is some pelvic contraction, we cannot expect the 

head to engage, unless late and some accident may hap- 
pen during the version which may demand immediate 
extraction. We sometimes turn from cephalic presenta- 
tion to pelvic presentation in contracted pelvis. 

3. Version by the head in the absence of this condition is 

harder and often impossible. 
Version by posture is the least dangerous and should be tried, 
even late in the first stage. You are almost always called to trans- 
verse presentations late, when the bag of waters is ruptured or when 
attempts at delivery have caused violent contractions, but if you have 
a case in pregnancy or in the beginning of labor, must try it. In' 
cases where the head has just slid off to one side, resting in one 



406 NOTES ON OBSTETRICS—SENIOR CLASS. 

iliac fossa, this method is ahiiost certain. If this does not do, 
or if you see that it will not, Wiegand's method: One hand over 
head, one over breech, and with alternate pushing and stroking 
movements, try to bring the head over the inlet. If accomplished, 
put patient on the side on which the head had been. 

If the bag of waters has now completely dilated the cervix and 
OS, and if no parts have prolapsed alongside the head, rupture the 
membranes. If these not present, keep the head over the inlet by 
posture. If neither method succeeds, we may try to turn by the 
combined internal and external procedure. 

Wright's is a combined internal and external method. 

Very few obstetricians now-a-days turn by the head by this 
method. If the cephalic version does not succeed by the given 
means, they turn by the feet ; indeed, cephalic version in trans- 
verse presentation is more theoretic than practical (excepting in the 
oblique presentation), because: ist, we are usually called too late; 
2nd, there is usually a contracted pelvis, which contra-indicates the 
cephalic presentation, or some anomally which makes the cephalic 
version more difficult than podalic version, and often one is so glad, 
in a given transverse presentation, that it is possible to turn by the 
feet, that a cephalic version is not considered, it being harder. The 
most frequent operation in transverse presentation is version by the 
feet, and it is this that is meant when we speak of turning or version, 
in transverse cases. 

Review — Treatment of transverse presentation — 

During pregnancy, version by posture, i. e., let the patient lie 
on that side on which the head lies (when in bed). Keep this 
up for two weeks. If still persists — 

Version by external manipulation. 

Version during pregnancy means cephalic version, and there 
must exist the three conditions which govern the procedure : 

(i) Absence of any immediate or prospective indication for the 
rapid termination of labor. 

(2) Presence of a high degree of mobility of the fetus, i. e., few% 
weak or no pains, bag of waters intact. 

(3) Absence of the slightest pelvic contraction. 

Of course, the first and second conditions are present during preg- 
nancy. Under these conditions version almost always succeeds. 
But often the fetus takes its original position again. 

During the first stage of labor, and even in the second stage, 
try external version, and posture. We turn by the head if the three 
conditions are present. 

We do podalic version in transverse presentation — 

(i) When cephaUc version has been tried and failed. 



NOTES ON OBSTETRICS—SENIOR CLASS. 407 

(2) When there is some immediate or prospective indication for 
the rapid termination of labor. These indications coming from the 
mother or fetus. From the mother, such as fever, exhaustion, hemor- 
rhage. From the fetus, asphyxia, as shown by increase or slowing 
of the fetal heart tones, and escape of meconium with the liquor 
amnii, etc. 

(3) When there is some pelvic contraction. 

The methods are the same as in cephalic version, excepting 
"posture." This we cannot use, save to assist the other methods. 
External manipulation finds its greatest usefulness here, because 
it involves little trauma, and should be tried whenever possible. The 
procedure is the same as in cephalic version, but we strive to bring 
down the breech and force up the head. In a multipara, with intact 
bag of waters, often succeeds, but may not if strong pains are 
present. Operate between pains, holding at each uterine con- 
traction that which you have gained. May even give an anesthetic. 
After the breech has been brought to the inlet, if the cervix is ef- 
faced and the os dilated, may rupture the bag of waters ; if these 
two conditions not present, put the patient on the side from which 
you have brought the breech and wait. Should any indication now 
arise for the immediate termination of labor, you must go into the 
uterus with one hand and bring down a foot on which to extract. 
This is one of the objections to version by external manipulation and 
causes us often to wait till the parts are ready so that we can turn 
and extract at the same sitting. 

In oblique breech presentation, i. e., where the breech has simply 
slid off to one side, in the iliac fossa, external manipulation almost 
always succeeds. 

Third Method — Internal and External, or "Combined." When 
we speak of version in transverse presentation we mean internal ver- 
sion, and usually version with the bringing down of one foot. 

There are two methods — 

(i) Braxton Hick's method, — hand in vagina, two fingers in 
uterus. 

(2) Version Proper, — whole hand in the uterus, aided by the 
outside hand. 

Which of these methods is used depends on the condition of the 
cervix and the mobility of the fetus. If the cervix is completely di- 
lated, you do version proper, rupturing the bag of waters, if neces- 
sary. If the cervix is not dilated and the bag of waters intact, wait ; 
but do not go away, stay by the patient so as to interfere when 
needed. If the cervix will admit only two fingers, but the bag of 
waters be ruptured, do -Braxton Hick's version. Do not wait after 
bag of w^aters is ruptured for the cervix to dilate to a size sufiicient 
to allow the hand to pass through, but do Braxton Hick's version. 



408 NOTES ON OBSTETRICS— SENIOR CLASS. 

It will serve to present the subject more clearly if we consider 
version proper first, taking up Braxton Hick's method later. 
Version Proper in Transverse Presentation — 
Conditions — 
(i) Cervix effaced, os dilated to admit the hand. 

(2) Pelvis not too contracted, not less than 8 cm. in flat pelvis, 
and 81^ cm. in generally contracted. The author extracted a small 
child through a c. v. of 7% cm., but not to be counted on unless it is 
positively known the child is small. 

(3) Uterus must not be in tetanus or retracted over the fetus, i.. 
e., no neglected transverse presentation. 

(4) The fetus must be mobile, i. e., not engaged, or at least, 
easily displaced. 

These conditions, how^ever, must be stretched as far as is 
safe for the mother, since the alternatives are desperate, 
e. g., embryotomy or Caesarean Section. 

(5) Under certain conditions the fetus must be living. 

Preparations — 

(i) Bladder and rectum empty. 

(2) Patient on a table, on back. Do not operate in bed, in justice 
to yourself, the patient and the child. 

(3) Antisepsis and asepsis, subjective and objective, extreme. 

(4) Have everything ready for treating asphyxia of the fetus. 

(5) Anesthetize the patient. 

(6) Accurate diagnosis of presentation and position. 

A. Which hand will you use? 

Rule — Take the hand whose palm wall be toward the breech 
when placed in the uterus ; therefore, when the breech is to the right, 
the left hand, — when to the left, the right hand. Reason is plain. 

B. Bag of Waters — What shall you do wdth the bag of waters 
should you be fortunate enough to get to do version before its rup- 
ture ? 

Three methods, according to three masters : Levret, Deleurye and 
Hueter. 

Levret — Ruptures the bag of waters in the cervix and puts the 
hand inside the membranes. 

Deleurye — Separates the membranes from the uterus till he 
reaches the level of the feet, then ruptures the bag of waters. 

Hueter — Does like Deleurye, but brings down the foot and then 
ruptures the bag of w^aters. 

The first method is the one of election. Dangers of infection, air 
embolism and separation of the placenta attend the others. 

C. Which foot shall you grasp, — or, shall you take two feet? 
Turn on one foot. 



NOTES ON OBSTETRICS—SENIOR CLASS. 409 

Take lower foot in anterior and upper foot in posterior positions. 
Why? 

Scapula Left Anterior (the most common) — Place the fingers 
of the left hand together, in the form of a cone, well lubricated with 
sterilized vaseline, or lysol, or i :iooo bichloride in glycerine, and 
with a gentle, boring motion go through the vulva, vagina and 
cervix. Place the other hand on the uterus, to prevent its recession 
from the advancing hand. After the hand has gotten into the uterus 
(sink the elbow well, to get beyond the promontory of the sacrum), 
place the other hand over the extremities and force these against 
the internal hand. Pass the hand directly along the belly of the 
fetus to the extremities and grasp the under foot. This is the foot 
more easily reached. Be careful of the cord and do not bring down 
a hand. The points which mark the hand are : ( i ) the length of 
the fingers; (2) no heel; (3) round palm, while the foot is long ; 
(4) great mobility of the wrist; (5) followed up you feel the elbow 
which is characteristic. If you should bring down a hand, put a 
sling on it. 

Grasp the foot with two fingers over the malleoli, the thumb 
against the sole. Now while this hand pulls on the foot, the other 
pushes the head up in the opposite direction, working outside. Work- 
ing together, between pains, rest during a contraction, the leg is 
finally brought down till the knee clears the vulva. 

Direction of traction is first dowmward toward the sacrum, then 
outward. When the knee appears at the vulva the version is com- 
plete, i. e., the head is in the fundus. The extraction of the fetus 
may not follow, but had better wait. Extraction of the fetus is an 
operation for itself, and has its own indications and conditions. 
Watch the fetal heart tones. Danger of separating the placenta dur- 
ing version, shown by the signs of asphyxia of the child and the 
occurrence of hemorrhage ; if these are present, proceed with the 
extraction. 

There is another method of reaching the foot. That of Baude- 
locque. Pass the hand to the back and down the leg to the ankle. 
Rule in back anterior positions is to grasp the lower foot. Rea- 
son is that the back of the fetus is kept anteriorly, which is of great 
importance in the subsequent extraction. What shall you do with 
the hand if it be prolapsed ? 

Do not push it back into the uterus, because you gain nothing 
by the procedure and it generally falls out again. Place a sling 
around the wrist. The arm recedes as the version is being made, 
and later the tape may be used to extract the arm with. If the cord 
is prolapsed, or prolapses- during the version, if it pulsates, good and 
well, wait ; if not, extract quickly. 

In certain cases the version does not succeed. The fetus will 



410 NOTES ON OBSTETRICS—SENIOR CLASS 

not turn. In these cases pull away from the obstruction, see that 
the uterus is relaxed, force head up with outside hand. But if the 
waters have ruptured and escaped since a long time it may be im- 
possible to turn. The reason is, that the shoulder is wedged in the 
inlet and by bringing down the foot the condition is not bettered. 
Can now use a procedure invented by Justine Sigmundine, a famous 
German midwife, called the "Double Manual" : Put a sling around 
the foot and while pulling on this, push the shoulder up out of the 
pelvis with the other hand. If this should not succeed, bring down 
the second foot, and then do the double manual on the two feet. 

A neglected transverse presentation is a most formidable case, 
since an attempt at version, or even the introduction of the hand may 
cause a rupture of the uterus. 

Version in Scapula D extra Anterior — This is the same, save that 
the right hand is used instead of the left hand. The lower foot is 
brought dow^n, as before. 

Rule — In all back anterior positions bring down the lower foot. 
In back posterior positions the upper foot. 

Version in Scapula D extra Posterior Position — Everything the 
same except that the operation is more difficult, especially the get- 
ting hold of the foot. These are anterior and one has to put the 
hand above the symphysis to reach them. This may be difficult; 
therefore, if cannot do it when patient is in the dorsal position, 
turn her to that side to w'hich the feet are. Then you can get by the 
inlet and the foot usually falls into the hand. Grasp the upper, if 
possible, hand outside assists as before. Reason for grasping the 
upper foot is to enable the back to come anteriorly. 

In extraction by the breech it is highly important that the back 
be anterior ; therefore, in turning, turn so that the back comes to the 
front. In order to accomplish this you must turn the fetus on its 
long axis, which is done by grasping the upper foot. Do this 
whenever possible, though experience has shown that even if the 
lower foot be grasped, the labor will usually terminate with the cor- 
rect rotation of the back. Do not waste too much time in hunting 
for the upper foot. (The term foot, means extremity.) 

Rule as to which hand to use the same. 

If, after putting the hand into the uterus, you find that you have 
made a mistake in the diagnosis, put in the other, after thorough 
sterilization. 

You will need the double manual and bringing down the second 
foot in back posterior positions more than in the others. 

The extraction and its difficulties were already considered, q. v. 

Braxton Hick's Version — In cases where you are called to a trans- 
verse presentation after the bag of waters is ruptured, but when the 



NOTES OX OBSTETRICS—SENIOR CLASS. 411 

cervix is just large enough to admit two fingers, you perform this 
operation. 

Do not wait for the cervix to be dilated by the pains so that you 
can introduce the hand, because the case may become a neglected 
transverse presentation under your eyes. 

Conditions — They are the same as for version proper, but the 
cervix need be large enough for two fingers only. The mobility of 
the fetus must be greater. 

The Preparations — These are the same as usual. 

Scapula Laeva Anterior — The whole hand is passed into the 
vagina as before, but two fingers only, passed through the cervix. 
The shoulder is pushed up to the left, at the same time that the 
external hand pushes up the head to the left. This motion is 
continued till a knee is felt. To favor the descent of the breech 
you may press the feet toward the hand inside. After the knee can 
he seized by hooking the finger into the popliteal space, or one finger 
can extend the leg while the second, in the space, brings down the 
foot so that it can be grasped. By using the external hand power- 
fully this method will often succeed. Bring the foot out through the 
cervix into the vagina, if possible. If possible only to bring the 
"breech over the inlet, place the woman on that side from which you 
have brought the breech and wait till the cervix will admit the ex- 
traction ; or, if no indication to interfere, leave the case to nature. 

Braxton Hick's Version is of special use in placenta previa cases. 
Here extraction must not follow the version. 

Version in the other positions is done on the same principles. 
What is to be done if the cervix will admit but two fingers and 
Braxton Hicks' version not successful? 

Since the cause of the trouble is the premature rupture of the 
bag of waters, nothing is more rational than to replace the bag of 
waters as best we can. This is done by means of the colpeurynter. 
This is a soft rubber, pear-shaped bag, to which is attached a long 
rubber tube. After thorough sterilization (boiling 30 minutes in 
plain water), it is folded tc^ether and then connect^^d with a David- 
son syringe. Let it fill with a weak antiseptic solution. Remove 
all the air by holding the tube higher than the colpeurynter, then 
fold into as small a roll as possible, and, by means of a lo-inch 
forceps, pass it inside the cervix and membranes. Remove the for- 
ceps and fill the colpeurynter. When it is full place an artery forceps 
on the tube and bring it over one groin. The pains now usually 
improve, the shoulder is prevented from entering the pelvis, what 
liquor amnii is left is prevented from escaping, and the cervix is di- 
lated by a soft body resembling very much the bag of waters. After 
the colpeurynter is expelled, the cervix will admit the hand, when 
version proper may be performed. This operation is called intra- 



412 NOTES ON OBSTETRICS—SENIOR CLASS. 

uterine colpeurysis, and has quite an extensive application ; a fact 
that is not well enough recognized. Certainly, too little use is made 
of this useful instrument. 

Cephalic Version in Breech Presentation — The indications to 
change a breech presentation into a cephalic presentation are very 
few. In general, it is bad practice. It was done by the ancient 
physicians because they thought breech presentations were very dan- 
gerous. Now it is seldom performed, because breech presentation 
is eutocia. 

A single indication — An old primiparae with a breech presenta- 
tion. Here there is great danger of rupture of the perineum by the 
after-coming head, and further, the resistant soft parts may so im- 
pede the delivery that the child dies of asphyxia. 

Conditions — Same as for cephalic version in transverse presenta- 
tion : (i) Mobility of the fetus. (2) No pelvic contraction. (3) 
No indication for the termination of labor. Method practiced is by 
external manipulation. 

Dangers ar^^-Detachment of the placenta ; coiling of the cord, 
and recurrence of the breech presentation. All things considered, 
cephalic version in breech presentation is very seldom performed. 
We have better means of handling such cases. 

Pelvic Version in Cephalic Presentation — Since occipital presenta- 
tions are eutocia, some special indication must exist that causes us 
to change a head presentation for a breech. But there are conditions 
where a head presentation is relatively pathologic, i. e., offers less 
chances for mother and child, or either, than a breech presentation. 

Indications — Chief indication is pelvic contraction, and especially 
in contractions from 8 to 11 cm. in flat pelves, and 8^ to 10 cm. in 
generally contracted pelves. Simpson said that the head passes 
through the pelvis better when the head comes last than going first, 
owing to the different shape of the wedge. The plane that has to 
pass through the inlet is one drawn through the bi-parietal diameter. 
When the head precedes, the wedge is obtuse. When the head 
comes after the body, the wedge is more acute. 

Aside from this there may be some diminution of the capacity 
of the head by the escape of cerebro-spinal fluid, after the body is 
born (head under pressure of the pains, body only the pressure of the 
air). Doubtful. 

Aside from the theory, experience has proven that the head last 
comes through more easily. Experiment also on the cadaver shows 
that the head comes through more easily in this manner. Further, 
we have a good handle to forcibly extract the head (the body), and 
by pressure from the outside we can force the head past the con- 
striction. 

The question is, whether it is more dangerous to the mother to 



NOTES OX OBSTETRICS—SENIOR CEASS. 413 

force the head violently through the pelvis, or whether it is not 
better to wait till the pains have moulded the head so that it can 
pass through the inlet. This is the old argument between those who 
would do version and those Avho would pursue an expectant plan in 
labor, in contracted pelves. 

The dangers attendant on a long labor where the pains force the 
hard head against the bony rim of the inlet for hours, and even 
days, are, compression necrosis of the uterine, vaginal and bladder 
walls, fistulae and infection, and peritonitis after this ; further, the 
prolonged compression may cause necrosis of the skin covering the 
skull and cranial necrosis, even fracture of the skull. Fracture of 
the skull may occur in breech extraction also. 

Aversion under these conditions comes into competition with ex- 
pectancy, and later, if the head does not engage, the axis-traction 
forceps, and is called ''Prophylactic Version." Pare, 1585, recom- 
mended this procedure, also his pupil, Guillemau. Symphyiotomy 
and Caesarean section also entering this field, since the infant mor- 
tality of the operation is high. 

IL Abnormal presentation of the head, e. g., anterior and pos- 
terior parietal bone, or ear, presentation. These are usually due to 
a contracted pelvis. Great danger of rupture of the uterus in these 
cases. 

III. Face presentations, with the chin persistently posterior. 
There are two methods of treatment, one to change to a vertex ; the 
other, version and bringing down a foot. 

IV. Prolapse of cord or extremities. 

V. Placenta previa. Here we have the head presentation, a rela- 
tively pathologic one, in that the woman may die from hemorrhage, 
while, w^hen the breech is in the lower uterine segment, it acts as a 
tampon, pressing the placenta against the uterine wall, and stopping 
the hemorrhage. 

VI. Any condition of the mother or fetus which indicates the 
rapid termination of 'labor, when the conditions for the forceps 
operation are not present, e. g., engagement of the head. 

Such emergencies are, heart disease, exhaustion, weakness of the 
powers of labor, eclampsia, etc. 

On the part of the fetus : Threatened asphyxia in utero. We 
wish in these cases to get some hold on the fetus. Unless the head 
is in the pelvis, wx cannot grasp it with the forceps, therefore, w^e 
turn and now can make the extraction by the feet. 

Conditions— -Sdixn^ as for version from transverse presentation to 
breech. The cervix must admit two fingers for Braxton Hick's 
version and the hand for combined version. Uterus must not be in 
tetanus, or not near rupturing. Head must be movable, i. e., not 
engaged ; pelvis roomy enough for the subsequent extraction. 



414 NOTES ON OBSTETRICS—SENIOR CLASS, 

Operation — We have again two methods : Braxton Hick's, and 
version proper. The same conditions influence us as in making- 
the selection in transverse presentation : 

We do Braxton Hick's Version when the mobility of the fetus is 
great and the cervix admits only two fingers. 

We do Version Proper when the cervix admits the hand, and 
when the fetus is more fixed. 

What foot will you bring down? 

Rule — Always the anterior foot. Then the back will come an- 
teriorly and the extraction be easy. If you bring down the posterior 
foot, the anterior buttock may catch on the symphysis and impede the 
extraction. 

You proceed the same as in transverse presentation, but you pass 
the hand further into the uterus. Push the head up with the other 
hand. Version is generally easy, but it may be necessary to go 
in for the other foot, or use the double manual. First, push the head 
inward on the chest of the baby, this to make a round ball of the 
fetus, so that it will rotate more easily ; then, when the foot is down,. 
push up on the head, which straightens out the trunk. 

Force to Be Used — In all versions the force used should be the 
gentlest possible. The uterus may tear very easily, and if this is 
perceived the hand must be immediately withdrawn and another 
method of delivery chosen. 

CHANGES IN THE POSTURE OF THE FETUS. 

I. Face Presentation — 

Some authors, especially the older ones, advised to change every 
face presentation to a vertex. Face presentation is eutocia. The 
majority will terminate spontaneously, but they require a long time.. 
Under certain conditions you may change a face to a vertex presenta- 
tion : 

( 1 ) When the chin remains persistently posteriorly, and the head 
be not engaged. 

(2) When there is delay in labor, causing danger to the fetus 
or mother, the head not being engaged. 

It is important to know these three facts : 

1. That in face presentation, anterior rotation of the chin does 
not occur till late, i. e., till the chin is pressed well against the pelvic 
-floor. 

2. The head seems engaged long before the parietal bones have 
passed the inlet. This is owing to the long distance from the 
parietal bosses to the face, and short distance to the occiput. 

3. That labor in face presentation is very long and tedious. 



NOTES OX OBSTETRICS—SENIOR CLASS. 415 

There are several methods of changing- a face presentation to a 
vertex: 

1. Baudelocque, — internal manipulation. 

2. By external manipulation, — that of Schatz. 

3. Thorn, — combined method, internal and external. 

4. Author's method. 

Baiidelocque's Method — Consists in forcing up the chin and then 
pulling down the occiput with fingers in the lower uterine segment. 

Schatz' Method — This consists in pulling the shoulders upward 
and backward, while the breech is forcibly pressed down toward 
the face. Hard to execute. Often unsuccessful. 

Thorn's Method — Consists, ist, in forcing up the chin, face and 
forehead, with n hand in the uterus, then with the external hand, the 
shoulder is pulled toward the back, so as to make the anterior sur- 
face of the fetus concave, while an assistant's hand pulls the breech 
to the side opposite to that to which you pull the shoulders. The 
head having been brought with the occiput presenting, put the woman 
on that side to which the occiput points and wait. 

Author's Method — 

(i) Inside hand pushes up and frees head and shoulder from 
grasp of uterus. 

(2) Push up chin, and press down occiput from outside. 

(3) Push shoulder and chest into concave shape from inside 
uterus. 

(4) Force dow^n breech and lead the flexed head into pelvis. 

PROLAPSE OF ONE OR BOTH HANDS WITH THE HEAD. 

This is usually due to contracted pelvis, a small fetus or a sudden 
escape of the liquor amnii. Often recognized only after the birth 
of the head, and then it may explain some delay in the second stage, 
or error of rotation. The finding alongside the head, while the lat- 
ter is still high up, is not rare. As the labor goes on usually the 
hand is retracted or pushed aside from the advancing head. Real 
prolapse of the hand occurs once in 237 labors, about. Dead fetuses 
are likely to have this complication, because the tonicity of their 
muscles and joints is gone. 
Treatment — 
I. Before the bag of waters ruptures, while the head is still 
above the inlet. Posture — To that side on which the hand did not 
prolapse. Usually suffices. 

11. After the bag of waters ruptures : 

(i) If the arm has prolapsed and the head be not engaged, if 
the arm appears to prevent the engagement of the head, 
replace it by the hand, then force the head into the 



416 XOTES OX OBSTETRICS—SENIOR CLASS. 

])elvis with the outside hand. We replace because we 
do not know if there is room for both in the pelvis. If 
the reposition does not succeed, or if the arm falls 
down again, do podalic version, when the conditions 
are present. 
(2) After the head is engaged, don't do anything, since there 
is room for both in the pelvis. Still, the increase in 
the size of presenting part makes labor in the second 
stage longer and sometimes anomalies in the rotation, 
therefore, forceps is more frequently necessary. In 
applying forceps, be careful that the blade does not 
grasp the arm between it and the head. 
Errors in rotation and delay in labor depend largely on the hand 
that prolapses, and its relation to the point of direction, e. g., if in a 
L. O. A. position the posterior arm comes down, it will aid rota- 
tion ; if the anterior, will delay or prevent it. If the arm and cord 
prolapse, do version. 

A rare anomaly in the posture of the fetus is when the arm is 
thrown back into the nape of the neck and lies across the inlet. The 
diagnosis is difficulty requiring the half-hand and the case is usually 
formidable. Treatment is to bring the arm into better position with 
the hand, under deep anesthesia. 

Prolapse of the Foot Alongside the Head — Feet seldom come 
down with the head. If they do^ they may cause delay in labor, 
necessitating forceps. If the feet prolapse at the inlet, and impede 
engagement, do podalic version, which is usually quite hard, while 
one would think the contrary. The "Double ^Manual'' is generally 
needed. 

PROLAPSE OF THE CORD. 

Prolapse of the cord is a rare complication of labor. Occurs 
1 :400 cases, but no accurate statistics possible. 

Causes — Anything w^hich causes imperfect apposition of the lower 
uterine segment to the presenting part, or prevents engagement 
of the head. Thus, there is room alongside the part for the cord 
to prolapse. In normal head presentations the lower uterine seg-. 
ment is so well applied to the head that the cord has no room to pro- 
lapse. Such causes are — ■ 

(a) Contracted pelvis : Here the presenting part is not engaged 
in the pelvis, the lower uterine segment hangs on each side of 
it, and there is plenty of room for the cord to come down. Impor- 
tant factor, so when you see a prolapse of the cord in a primipara, 
there is usually a contracted pelvis. 

(b) iMalpositions of the head, e. g., face presentation, brow 
presentation, prolapse cf a hand with the head. 



NOTES ON OBSTETRICS—SENIOR CLASS. 417 

(c) Breech and transverse presentations, — same reason. 

(d) Hydramnion. Rupture of the bag of waters early in labor, 
head being high up, therefore, commoner in multiparae. 

(e) Accident, rush of the waters while the head is high up. 

(f) Low insertion of the placenta. Cord near os. 

(g) Length of the cord has some influence, but even a very short 
cord may prolapse. 

We speak of the forelying cord, when the cord is found before 
the head in an intact bag of waters. After rupture of the bag of 
waters we speak of prolapse, — whether the cord remains in the vagina 
or comes out of the vulva. ^ 

Dangers of Prolapse — 

For the mother — None, save those which are incident to the 
conditions which caused the prolapse and those incident to opera- 
tions which are undertaken in the favor of the child. Mortality, 
therefore, is very low. 

For the child — The dangers are great. Danger of compression 
of the cord by the presenting part, against the pelvis, causing 
asphyxia (not inanition, as the time is too short). The cause of 
the asphyxia is the interruption of the circulation, the result of the 
compression. Formerly held that the cord, when lying outside the 
vulva, becomes cold, and, therefore, the fetus dies. This may cause 
difficulty in the circulation of the blood through the cord, in that 
the cold contracts the blood vessels ; further, the patient may lie on 
the cord and kill her child. A practical hint here, — keep the cord in 
the vagina. 40% to 50% of children die in these cases; 80% die 
when left to nature. 

Diagnosis — 

1. Before rupture. 

A careful examiner may find the pulsating cord in the bag of 
waters before the head. Go carefully to the side and high up, if 
there is suspicion, as sometimes a small knuckle hangs down the 
side of the head, which is important to know, if forceps is to be 
applied. Most often the diagnosis is made after rupture. Differen- 
tiate from velamentous insertion of cord and from cervical vessels 
pulsating, 

2. After rupture. 

Generally no difficulty, feel the cord in the vagina, or may see it 
outside the vulva. If it has stopped pulsating, more diffi'cult to diag- 
nose. Must remember that the pulsation may be absent for a short 
time, and still fetus be living. This is true, especially during a pain, 
so do not say the fetus is dead too hastily. Control by the ausculta- 
tion. 

Treatment — Prolapse of the cord has an importance varying 
greatly with the presentation. In transverse presentation it has lit- 



418 NOTES ON OBSTETRICS—SENIOR CLASS. 

tie importance ; in breech, more ; and the most in cephalic presenta- 
tion, especially of the occiput. This is due to the varying pressure 
of the presenting part on the girdle of resistance ; the greater the 
pressure, the greater the danger of asphyxia. 

In Cephalic Presentation — We must accomplish one of two pur- 
poses : 1st, must free the circulation of the fetus ; or, 2nd, must make 
it possij^le for the fetus to get air. In other words, we must place 
the cord where it will not be compressed, or we must extract the 
child. 

I. In cases where the cord is felt in an intact bag of waters, re- 
place by posture. Put the patient on that side on which the cord is 
not, or in the knee-chest posture. To relieve her, Trendelenberg 
posture. Retard the rupture of the bag of waters as long as pos- 
sible ; therefore, be careful in examinmg. Put in a colpeurynter. 
If a large coil of the cord is felt, and posture not successful, wait 
until the cervix is large enough to admit the hand, then the case is 
treated as under next heading. Do not leave patient. 

II. Cases where the cord prolapses. Everything depends upon 
the cervix. If it is not dilated, it is a bad case, almost always the 
baby dies. In these cases, Braxton Hick's version, or replace by 
posture, by two fingers, or by means of a catheter with a stylet. Op- 
eration difficult and usually the cord falls down again. In these 
cases put the patient on that side to which the occiput does not point, 
so as to favor lateral displacement of the head and wait. Replace 
the cord in the cervix and put in Barnes' bag. Often fetus dies 
while you are waiting. 

If tjie cervix will admit the hand we have two methods to choose 
from: ist. Reposition; 2, Version, atid Extraction. Results are 
equally good ; choose the easier in a given case. You must always 
turn and extract when there is (a) a face or brow presentation, or 
pathologic cephalic presentation, or a prolapse of the arm; or (b) 
any indication on the part of the mother or child which makes the 
immediate termination of labor desirable; (c) or where there is a 
contracted pelvis (frequently exists) ; (d) where reposition fails. 

Reposition — This is carried out with three points in view : 

1. Replace always in the knee-chest posture. If patient can 

not tolerate this, Trendelenberg posture. 

2. Replace rapidly, even if there is some compression of the 

cord. Rupture the bag of waters after the hand is in- 
troduced. 

3. Use the whole hand. 

Force the head over the inlet with the outside hand, and turn 
the woman on that side to which the occiput lies, holding the hand 
still inside the uterus. Do not turn her on her back, because the 
cord will fall down again. May hang the cord over a knee. 



NOTES ON OBSTETRICS—SENIOR CLASS. 419 

Conditions for the reposition are : 

1. The child must be living and in good condition. 

2. The pelvis must not be contracted. 

3. No indication for immediate termination of labor. 
Version — This performed under usual conditions. It may not be 

necessary to perform extraction immediately. Control heart tones, 
feel the cord. Indication for immediate termination lies in threat- 
ened asphyxia of the child. 

III. A group of cases where the head has engaged. 

No reposition or version possible, therefore, rapid delivery. . If 
child alive, forceps quickly. Sometimes delivery is spontaneous; 
which you aid by exhorting the woman to bear down strongly. If 
fetus dead, craniotomy. Sometimes called to a case when the cord 
is pulsating very faintly, or not at all. What to do? Remember 
to assume yourself that the fetal heart really has ceased beating. If 
it has only very recently stopped, or if it is pulsating weakly, justifi- 
able to do a version and extraction. Must have favorable outlook 
for a live baby. If the child has evidently been dead some time, 
you may leave the case to nature in a multipara, with normal pel- 
vis ; in a primipara, do a craniotomy, if delivery is indicated. Do 
not apply the forceps to a dead child, nor turn and extract a dead 
child (except under unusual conditions). Accurate diagnosis must 
be insisted on. 

Prolapse of the cord in a breech presentation or footling — Sel- 
dom necessary to do anything. Wait for some indication. Extract 
if the conditions are present. 

In Transverse Presentation — No change in the treatment. ,Re- 
place cord in vagina, during preparations for version. 

SUMMARY OF TREATMENT OF PROLAPSE OF THE 

CORD. 

(i) Before Rupture of the bag of waters POSTURE— side, 
knee-chest, Trendelenburg. If not successful, wait till cervix admits 
the hand and replace, or do version. 

(2) After Rupture of the bag of waters — 

A. If cervix not large enough for extraction: 

1. Braxton Hick's Version. 

2. Reposition, — catheter, fingers. 

3. Put cord in cervix and then Barnes' Bag. 

B. If cervix will admit whole hand, two methods : 

1. Replace the cord. Three points — Rapidly, knee- 
chest position, use whole hand. 

2. Version by the combined method, followed by ex- 



420 NOTES ON OBSTETRICS—SENIOR CLASS. 

traction if necessary. Version preferred when there 
is some other condition making- breech presentation 
desirable. 
(3) After Head Has Engaged — 

Neither reposition nor version possible, therefore rapid de- 
Hvery. If child is alive, forceps. If child is dead, leave 
case to nature, or craniotomy. 

MUTILATING OPERATIONS ON THE CHILD. 

Undertaken in favor of the mother: 

The operations thus far discussed v^ere operations undertaken 
in favor of the child and the mother. We now have to consider op- 
erations in favor of either, at the expense of the other. 

First — Operations intended to deliver the mother with the least 
danger to her and with no regard of the child. 

They may all be grouped under the general term Embryotomy, 
which means section of the fetus. But the term embryotomy has 
come to be used in a restricted sense, and is employed to designate 
operations on the trunk of the embryo. 

Craniotomy is an operation which consists in opening the fetal 
head, the evacuation of the cerebral matter, and extraction by 
means of a large bone forceps or a sharp hook. 

Perforation is the first step in the operation of craniotomy, but 
is sometimes applied to the whole operation. 

Cranioclasis is the the third step in the operation, and is also 
sometimes applied to the whole operation. The instrument, which 
is nothing more or less than a large, strong, especially constructed 
bone forceps, is called a cranioclast. 

Cephalothrypsis is an operation in which the head is crushed by 
means of a powerful forceps, supplied with a compression screw, 
no perforation of the head being made. The instrument is called a 
cephalothryptor. 

Decapitation means what it says — section of the neck, and is ac- 
complished either by means of a blunt hook or a sickle-knife, or the 
ecraseur, or scissors. 

Embryotomy is applied to decapitation, or to the section of the 
fetal trunk, to the opening of the body cavities. 

Exenteration means disemboweling the fetus, to diminish the 
size of the trunk. 

Brachiotomy means section of an arm. 

Cleidotomy is an operation introduced by Phenomenoff in 1895. 
It is section of the clavicles, and used when the shoulders are too 
broad to pass, the head being delivered and the child dead. Recently 
recommended but not practiced by a French author for living child. 



NOTES ON OBSTETRICS—SENIOR CLASS. 421 

CRANIOTOMY. • 
The Indications for the Operation. 

I. On the Dead Fetus — (a) When the child is dead, labor de- 
layed and any indication for the rapid termination of labor arises, 
e. g., eclampsia, rupture of the uterus, threatened or occurred; ede- 
ma of the lungs, etc. We must modify this statement in private 
practice, for sentimental reasons it may be necessary to employ the 
forceps, but if the conditions for forceps are not present, e. g., when 
there is a small cervix, contracted pelvis, or large baby, the best 
and quickest way of delivery is by craniotomy. Do not do a hard 
forceps operation or version for a dead child. 

(b) When the child is dead, there being no indication for the 
rapid termination of labor. Here we want to deliver the mother 
with the least amount of injury, as there is nothing to be gained. 
In a primipara, I would advise a craniotomy. In a multipara, leave 
the case to nature. If a face presentation, or a brow, or anything 
that will cause tears of the parts, prefer the craniotomy. In hospital 
practice always do it, but in private practice have to be guided 
somewhat by the family, who will usually object to disfigurement of 
the body, or may ascribe the death to the operation. In cases of 
delay of the after-coming head when the child is dead, take plenty of 
time, or perforate. 

Of course if there is any doubt about the life of the child, it must 
get the benefit of it. 

II. When the child is living the indication is very much harder 
to place, and is very often dependent, not on therapeutic grounds, 
but on clinical experience, the acuteness of the accoucheur in prog- 
nosis, and often enough on religious prejudices. 

(a) When the spacial disproportion is such that it is impossible 
to deliver the child without grave injuries to the mother, e. g., any 
tumor of the pelvis, contracted pelvis, large head of the fetus. When 
the pelvis is more than 8 cm. (i. e., the conjugata vera), version 
and extraction. When less than 6 cm. there is no alternative ; must 
do a Caesarean section. When from 6 to 8 cm. three operations : 

1. Craniotomy on the living child. 

2. Caesarean section from the relative indication. 

3. Symphysiotomy. 

The decision is hard to make, and depends upon the condition of 
the patient, whether certain operations have been tried, and the 
surroundings'. 

Between Caesarean section and craniotomy, remember that the 
favorable time for the former is early in labor, before many exami- 
nations have been made and no operative attempts at delivery. After 
this time the prognosis is bad. Can do a craniotomy on this child 



422 NOTES ON OBSTETRICS—SENIOR CLASS. 

and induce premature labor on the next. Do not consider Caesarean 
section unl'ess the child is m good condition, i. e., heart tones good, 
no meconium, etc. Remember that conception is not so likely to 
take place after Caesarean section. 

If the woman wants children do craniotomy this time and pre- 
mature labor on the next. Give her the question unvarnished. 
Mortality of craniotomy is near zero, whereas Caesarean section at 
least 5% and under the conditions usually met, up to 40%. 

Symphysiotomy has a mortality of 12%, a like per cent of chil- 
dren die, there is danger of permanent disability, from non-union 
of the pubis, of incontinence of urine, and of chronic suppuration 
of the pelvic joints. Field of symphysiotomy is 6 to 8 cm. Under 
very favorable conditions, when the fetus is in good condition and 
not too large, I think symphysiotomy is justifiable. When severe 
operations have already been undertaken for the delivery of the 
child, the probability of a good result is bad for symphysiotomy, as 
it is for Caesarean section, and in these cases it is better to do a 
craniotomy. Call a consultation to protect yourself. It is not justi- 
fiable to wait in these cases till the child is dead, because here you 
would expose the patient to great dangers. If the head is fixed in 
the inlet, it is justifiable to try the forceps, i. e., high forceps, which 
is always an instrument of trial. If eight tractions are properly 
applied and there is no progress, do craniotomy. If while doing a 
forceps operation, the resistances met are greater than expected, so 
that it is impossible to get the child through without serious injury 
to the child and mother; if after attempting a version in cephalic 
presentation, for contracted pelvis, this be found impossible, may 
do a craniotomy. If the case is hopeless for the child, and the family 
desires Caesarean section, refuse the case. If the chances are excel- 
lent for the child and nearly as good for the mother, may recom- 
mend heartily the Caesarean section, but you will have to abide by 
the decision of the family, as they have the right to decide. They 
do the craniotomy under these conditions. 

(b) Face presentation, when the chin is posterior, when time 
for changing to vertex, and for version has past and some indication 
for the termination of labor arises. 

A careful application of the forceps is to be made, but under no 
circumstances is this to be forced, because the dangers to the mother 
are too great and the fetus almost always dies, either during the 
labor, a few hours after from asphyxia, or in a few days from the 
injuries inflicted and atelectasis pulmonum. 

Conditions — 

(i) Head need not be engaged, better if fixed. 
(2) Cervix effaced and os dilated sufficiently for the subse- 
quent extraction — at least four fingers. 



NOTES ON OBSTETRICS— SENIOR^ CLASS. 423 

(3) Pelvis not too contracted, not less than 6 cm., because 

here you cannot get the child through. 

(4) Bag of waters ruptured, easily procured. 
Preparations same as for any obstetric operation. Anesthesia 

almost always necessary and desirable to spare woman's feelings. 
The operation is divided into three steps : 

I. Perforation of the Head — x\ccomplished by means of Martin's 
or Guyon's trephine. Some authors advise Naegele's perforator, 
which is shaped like a glove stretcher, but with a cutting edge. A 
careful man can do no harm with the sharp instrument and it will 
usually suffice. Four lingers are passed inside the cervix and tips 
laid on the head. Point of the Naegele instrument carefully passed 
along fingers to the head and sunk into the scalp. Examine to see 
that it lies well and no maternal tissue caught. Then with a firm, 
slightly boring motion, force the instrument through. Have someone 
fix the head from the outside or grasp the scalp with a stout vul- 
sellum forceps. Better to go through a suture, if you find it handy, 
but the perforator goes quite easily through the bone. Now separate 
the blades after unlocking. Now lock the instrument, turn 90 
degrees and open again, then lock and under the guidance of the 
fingers withdraw the instrument. The trephine is used in like man- 
ner under guidance of the fingers. 

II. Excerebration — By means of a long douche point break up 
the brain matter, letting a stream of ^% lysol run through at the 
same time. Be sure to break up the basal ganglia, because the child 
may live, perhaps days, if not done. 

III. Act of Extraction — No hurry at all. If the parts are not 
dilated may leave the case to nature. 

Instrument of election is the cranioclast, Braun's or the author's 
three-bladed instrument. Simply a large bone forceps, with a 
strong compression apparatus. Solid blade is passed inside the skull, 
if possible, into the spinal canal, the other blade passed, preferably, 
over the face, because it gets a better grasp here. Same rules as 
passing the forceps. After being passed, examine to see if anything 
beside the head is caught in the grasp of the instrument. Lock and 
screw together slowly. Screw down tightly. Now gently extract, 
using the same rules as in forceps, i. e., intermittent traction, sta- 
tionary traction, in the direction of the axis of the inlet. Be careful 
that no splinters cut the vagina. Cover them with the fingers. 
If the instrument tears out, reapply it, being sure that the blades are 
well down upon the head. The three-bladed instrument will not 
slip off. 

In craniotomy in face presentation, the perforator is placed on the 
forehead, at the glabella, or throrgh one eye. This is the easier. 
Otherwise the operation is the same as before. When perforating 



424 NOTES ON OBSTETRICS—SENIOR CLASS. 

the after-coming head, may go through the occipital bone, or under 
the chin, or, best of all, through the base of the skull, by way of the 
mouth, when the wound is hidden — an advantage. Operation is 
more difficult than otherwise. 

Prognosis — Prognosis of the operation is good ; in good hands, 
and with good condition of the woman, none should die. 

DECAPITATION. 

Rare operation, i : 10,000. Old as Hippocrates, who did it with a 
curved knife. He also did craniotomy on the living and dead child. 

Indications — Most common : 

(i) Neglected transverse presentation — 

Great danger of rupture of the uterus, if you try to turn, there- 
fore in all cases where the child is dead, do not try to do a version. 
If the child is alive, a gentle attempt at version, in deep anesthesia, 
may be made. Where the lower uterine segment is thinned out, the 
uterus drawn up over the child, the contraction ring at or above the 
navel, embryotomy. 

(2) Twins interlocked — Some authors advise to do a decapita- 
tion on the first child. It may be necessary to deliver the second 
first; nature does it this way. 

(3) Double monsters — 

In general it is bad practice in cases of double monsters to cut 
off the part which is delivered. Better to turn the child still in 
utero and deliver the two side by side ; but diagnosis hard and cases 
bad. See chapter on Teratology. 
Conditions — 

(i) Pelvis not too contracted, 6 cm. in flat, 6}^ cm. in gener- 
ally contracted pelvis. 

(2) Cervix dilated at least for four fingers. 

(3) Child dead or living? Usually is dead. Same argu- 

ments as for craniotomy. If mother desires, can do 
Caesarean section or symphysiotomy. 

Preparations the same as for any severe obstetric operation. 

Operation — Three acts : 

(i) Separation of the head from the trunk. 

(2) Delivery of the trunk. 

(3) Delivery of the head. 

I. Section of the neck is best accomplished by the dull hook of 
Carl Braun. There are many other methods but this is used mostly. 
Pass in that hand which will present its palmar side to the head. 
Put two fingers around the neck from behind, the thumb meets them 
from the front. Now" pass the hook along the thumb, from the 
front over the neck, and sink it well into the soft parts. To facili- 



NOTES ON OBSTETRICS—SENIOR CLASS. 425 

tate the whole maneuver, pull down the arm, which brings the neck 
into reach, and you must have it fully in your grasp in order to do 
the operation right. Now turn the hook so that the knob goes toward 
the head, pulling- down at the same time. One turn and you usually 
feel the neck break. Another bite and the soft parts are severed. 
Three bites are generally necessary. Ordinarily some of the last 
shreds must be cut with a scissors. 

II. Extract the trunk by traction on the arm, which always or 
almost always succeeds, protecting the maternal structure from being 
torn by fragments of bone. 

III. Extract the head by the finger in the mouth. If the pelvis 
is not contracted, use the forceps, but if any trouble at all, perforate 
the head and apply the cranioclast. Be careful that the broken verte- 
brae do not cut the vagina when coming out. 

In cases of neglected transverse presentation where you cannot 
reach the neck for a decapitation, the operation to do is eventra- 
tion or exenteration. Perforate the chest w^ith heavy scissors or the 
perforator, make a large opening, the hand now pulls out as best it 
can all the entrails, first the chest cavities, then through the dia- 
phragm to the liver and bow^els. After the two cavities are emptied, 
may extract by pulling on the arm, by means of a hook or the crani- 
oclast applied to the spinal column. Or the spine may be broken 
and the child doubled. 

OPERATIONS IN FAVOR OF THE CHILD. 

Involving mutilation of mother. 

I. Those which open new passages for the child, e. g., Caesar- 
ean Section, Laparo-Elytrotomy. 

II. Those which enlarge the existing passages, e. g.. Symphysi- 
otomy (bony pelvis) ; Hysterostomotomy (soft parts). 

The distinction between operations in favor of mother and child 
cannot be so very sharply defined, because any operation with deliv- 
ery as its object is in favor of the mother as well as the child, e. g., 
symphysiotomy. But we mean that this operation will give the 
child more chances, but gives the mother greater danger at the same 
time, in comparison with other operations which save the mother 
but kill the child. 

Sectio Caesar ea — Derives its name trom cedere, to cut, and has 
no relation to .Julius Caesar. The Talmud mentions the operation 
as "Jotze Dofan." The first authentic Caesarean section was by 
Trautman, in Wittenburg, 1610 — hernia uteri gravidi. Operation 
had been described by Rousset, in 1581. He based his description on 
fifteen cases which he had done, but a careful examination shows 
that these may have been extra uterine pregnancies. The swine 



426 NOTES ON OBSTETRICS—SENIOR CLASS. 

gelder Nufer in Switzerland had done a similar operation on his own 
wife. Rousset placed the indications and described the operation, so 
that he is usually considered the father of the operation on the living. 

Alortality was very high — sepsis ; did not sew uterus ; late for- 
lorn cases. Not till 1882, when Sanger (died 1902) improved the 
methods, did Caesarean section get a place in obstetrics. 

Method of Sanger — 

(a) Median abdominal and anterior uterine incision (still 

the best). 

(b) Resection of the uterine wall. 

(c) Accurate adaptation with buried and Lembert's perito- 

neal sutures. 

(d) Extreme asepsis and antisepsis. 

(e) Use of the temporary rubber ligature. 

(f) Drainage of the uterus. 

Great improvement came with this operation in the results, 
but later several of these items were found unnecessary, e. g., uterine 
drainage, Lembert's suture, resection of the uterine wall, and latterly 
even the use of the rubber ligature is being done away with and the 
hands used to compress the broad ligament at the sides of the uterus. 

The abdominal incision was made in many places and directions, 
now only one used, in the linea alba. Same is true of the uterine 
incision. Now only two in general practice, the median anterior 
recommended by Sanger, and the transverse fundal cut, introduced 
by Fritsch. Has, in my opinion, little preference. 

There are several operations under this caption : 

1. Conservative Caesarean section. 

2. Porro's operation, removal of the body of the uterus. 

3. Section with total extirpation of the uterus. 

4. Vaginal Caesarean section. 

Indications — These are absolute and relative, the scope of the 
latter being enlarged lately, with the increasing safety of the opera- 
tion. 

The absolute indication for C. S. exists when the parturient canal 
is narrowed so much that a child, even reduced in size, cannot get 
through with safety to the mother. This means an available C. \^. 
of 6 cm. or 6^^ cm. This narrowing may be in the bony pelvis, e. 
g., flat and generally contracted pelves, exostoses, tumors, etc., and 
in the soft parts, e. g., stenosis of the cervix, vagina, neoplasms of 
the uterus or adnexae prolapsed into the way of the child. 

If the patient has passed the twenty-eighth week, the time for in- 
duction of abortion is passed, so wx must let her go to term and 
perform abdominal delivery. It is not good to induce labor and to 
do symphysiotomy, too, as has been advised. 

If the woman is in labor there is no choice. Caesarean section 
is the only operation and often we extirpate the uterus also. 



NOTES ON OBSTETRICS—SENIOR CLASS. 427 

The relative indication exists when the choice Hes between crani- 
otomy on the Hving child and Caesarean section. This has almost 
always reference to contracted pelves though the relative indication 
can exist with other conditions, e. g., placenta previa (premature 
detachment of placenta). A pelvis with a C. V. between 6 and 8 
cm. if flat, and 6^^ and 8^ cm. if generally contracted, will very 
rarely allow a living child through, but one can easily mutilate the 
infant and get it to pass. The question is to be put to the family and 
all the facts and mortality percentages clearly laid open for consider- 
ation. The physician should not assume the responsiblity alone, 
but he may, if the conditions of the case warrant it, urge them to 
allow the section to save the child. 

Such conditions are — 

(i) An uninfected parturient canal, i. e., few or no exam- 
inations and surely no operations attempted. 

(2) Mother in good health to stand laparotomy. 

(3) Labor not too prolonged, i. e., patient must not have 

-been in hard labor more than 8 hours, or altogether 
more than 24 hours. 

(4) Child must be in good condition. Under these circum- 

stances the physician can conscientiously recommend 

the abdominal operation, if a man is on hand capable 

of doing laparotomies, and good facilities are to be 

had. But if they are not present, the patient's interests 

are better subserved if this child is sacrificed and the 

hope of premature labor or Caesarean section under 

ideal conditions is held out for the next pregnancy. 

The relative indication may not be said always to exist in cases 

of placenta previa. A large percent, nearly 40, of the children are 

lost in these accidents, and to save them the abdominal delivery has 

been proposed. In case of placenta previa with closed and rigid os, 

near term, C. S. may occasionally be practiced, but usually our 

methods of delivery from below will suffice. 

Caesarean section is not yet safe enough to be used solely to 
improve the chances of the child. 

Eclampsia is given as another indication, but it has not yet ob- 
tained general recognition. Prolapsed cord and premature detach- 
ment of the placenta are proposed but not widely recognized indi- 
cations for the operation. After the death of the mother the child 
should be delivered as rapidly as possible, and opening the abdomen 
is sometimes the quickest way, though in, a multipara the genitals 
could be in a few moments enlarged so as to permit instant delivery. 
Conditions — 

I. For the absolute indication the size of the pelvis is fixed — 
C. V. less than 6 or 6>4 cm., and it matters not whether the child 
lives or not, the operation is a necessity. 



428 NOTES ON OBSTETRICS—SENIOR CLASS. 

2. For the relative indication the child must be in prime condi 
tion. 

3. It is better if the labor is begun and there is some dilatation 
of the cervix, but neither is necessary. 

Preparations — The same as for any serious laparotomy, plus 
arrangements for treating asphyxia of the child. 

Need four assistants — one anesthetizer, one assistant for the 
baby, one assistant is opposite you, and one hands instruments, nee- 
dles (which should be all threaded beforehand) and sponges. Three 
pairs of clean hands only, all with perfect rubber gloves. 

Incision occupies the middle two-quarters of a line drawn from 
the fundus to the pubis. Go slowly because the walls are thin and 
it is easy to cut directly into the uterus. Open abdomen full length 
of incision, bring uterus out of wound by the left horn, cover it 
with a large warm gauze pad. Unite the abdominal wall behind 
it temporarily with three large vulsellum forceps. 

The assistant gets ready to grasp the broad ligaments near the 
base so as to control bleeding if it become too profuse, the knife 
makes a small cut in the median line of the uterus near the fundus, 
the scissors lengthen the wound to about 4^ inches. The mem- 
branes are now opened, the child is quickly extracted by the feet, or 
the head, if it is a breech presentation. The placenta now. usually 
falls into the free cavity. The cord is clamped in two places, and 
cut between, the child handed to the assistant deputed for this 
work, and the operator massages the uterus briskly, aiding the sep- 
aration of the placenta and membranes carefully determining that the 
uterus is clean. The uterus now contracts vigorously and the as- 
sistant removes his hands. The sutures are now placed, one layer 
continuous No. 2 catgut taking in muscle only, then an interrupted 
No. 2 chromatized catgut, ^ inch apart, through peritoneum to 
the first row. Then a fine careful peritoneal suture of finest catgut. 
Then the toilette of the peritoneum and closing of the abdominal 
wall. Omentum drawn behind uterus. 

Sometimes the uterus bleeds. Massage and compression with 
hot towels, ergot hypodermic, hot douche, uterine tampon, remove 
uterus. 

After-treatment same as any laparotomy. 

The child is often in a condition of apnea, but recovers under the 
usual treatment. 

Prognosis — In America, according to Harris, the general mor- 
tality is still 40%, but in the hands of skilled operators it is as low 
as 3%. These are selected cases, as Leopold, 3%. Dangers art- 
shock, hemorrhage and sepsis. For general purposes we can say 
TO% is the usual mortality. In 8 favorable cases the author had no 
mortality. In one primarily unfavorable case the mother succumbed. 

Child — If the child is healthy before the operation, ought to be 



NOTES ON OBSTETRICS—SENIOR CLASS. 429 

born alive, but nevertheless, mortality was formerly 25%, still 5%. 
Therefore the operation is still very serious for both. 

Later Effects — Hernia abdominalis. Utero-abdominal fistula — 
one case where fetus made exit here. Adhesion of uterus to ab- 
dominal wall — tendency to abortion. Subsequent Caesarean section, 
no opening of peritoneal cavity. Ruptura Uteri : Not observed so 
often now since uterus has been sewed. Uterus heals so well that 
sometimes cannot see scar. Muscle fibres develop in it. Silk encap- 
sulated and absorbed or discharged in about two years. 

Effect on- Subsequent Pregnancy — Latest statistics much better 
than old: 23%, and even in Chrobak's clinic 43%. Clinical observa- 
tion that conception not so frequent as after operations per natural 
passages. 

Operation of Porro — In 1877 Porro, of Pavia, devised an oper- 
ation to do away with hemorrhage and sepsis. After removing child, 
he amputated the fundus of the uterus and the adnexae, with extra- 
peritoneal treatment of the stump. This for some time seemed to 
replace Caesarean section because it gave a better prognosis, but 
after Sanger it has been limited. 

Indications — 

1. Myoma uteri. 

2. Osteomalacia. 

3. Sepsis, uterine. 

4. Great hemorrhage at Caesarean section. 

5. Ruptured uterus, torn too much or with sepsis. 

6. Carcinoma with stenosis of the cervix. 

No conditions. Operate at any time, when indication is plain. 

Operation — Same as Caesarean section till after placenta is re- 
moved. Broad ligaments ligated. Uterus amputated above liga- 
tures, then treat stump either intra or extra-peritoneally. Mortality 
formerly better than Caesarean section, but now worse. Only done 
under express indications. In some cases the uterus is removed in 
toto, and the vagina sewed together, then the peritoneum roofs 
over the pelvis. Done in cases where there are fibroids, or sepsis, 
or malignant tumors, etc. 

Laparo Elytrotomy — Incision parallel to Poupart's ligament. 
Dissect peritoneum. Incise cervix and lower uterine segment. 
Merely of historical interest. 

Sectio Caesarea on Dead or Dying — Child lives 6 to 15 minutes 
after death of the mother. Once it lived i^ hours. Depends on 
rapidity of death. Only i^ to 2% of children saved. Mother uses 
child's oxygen. Fetus suffers first. If death by accident, 5 to 6% 
saved. Old Jewish law in the Talmud and Catholic law, should do 
Caesarean section on dying woman, but it is hard to get consent of 
the friends, and then there may be a mistake in diagnosis — Strass- 



430 NOTES ON OBSTETRICS—SENIOR CLASS. 

burg, case mitral disease, cataleptic woman came to life again. Op- 
eration same as on living woman and as carefully. 

Vaginal Caesar ean Section — Diihrssen, in 1896, proposed this 
operation. It consists of an anterior colpotomy, then open the uterus 
longitudinally ; extract the child, sew up uterus and vaginal incisions, 
with or without drainage. 

Recommended for cases where, the pelvis being normal, there is 
an indication for rapid delivery at a time when the cervix is not 
effaced, e. g., eclampsia. Also for stenosis of the cervix from any 
cause. Operation is not hard to carry out. There is often great 
hemorrhage and it requires skill, more than for the abdominal 
method. 

Is very slowly obtaining a place in obstetrics, but the need for 
it will be a rare one. 

SYMPHYSIOTOMY. 

Certain operations have the enlargement of the bony pelvis 
as their aim. Of these the most commonly practiced is symphysi- 
otomy. This operation has had a very interesting history. 

It was devised by Signault, of Paris, in 1773, when he was a 
medical student, and he obtained a prize from the Academy of Med- 
icine for the thesis. He practiced it in 1777 for the first time, on 
the woman Souchot, the wife of a soldier. She had a urinary fis- 
tula, but finally recovered and the child lived also. 

The next three operations were all fatal and the obstetricians of 
the time raised a great clamor against symphysiotomy. Baudeloeque, 
La Chapelle, Du Bois, Cazeau, were among the opponents, though 
the last named said it might be successful in some cases, but never 
did it. It disappeared in France very soon, but took refuge in Italy, 
and has been practiced there more or less since. The School of 
Naples has kept it up especially, through the efforts of Galbiati and 
Morisani. The latter worked long and hard to obtain for it public 
recognition, but he could not get this till his results improved, 
which came with the advent of antisepsis. In 1891 Spinelli, an old 
assistant of Morisani, went to Paris and called the attention of 
Pinard to the operation. Pinard took it up with characteristic 
French enthusiasm and within a year had done 17 operations. As 
a result of the experiments of Pinard, after separation of the pubic 
bones of i cm. there is an increase of the conjugata vera of 2 or 
2^ mm. The increase of the separation of each centimeter means 
an increase of 2^ mm., but after the third cm. of separation there 
is an increase of 3 mm. According to Pinard, the increase is greater 
in contracted pelves and greater the more the pelvis is contracted. 
The increase is in all the diameters, in the outlet as well as the inlet. 
The transverse diameter enlarges one-half as much as the bones 



NOTES ON OBSTETRICS—SENIOR CLASS. 431 

separate, the bi-ischiatic about three-quarters as much as the sym- 
physis separation. The extent of the enlargement of the diameters 
depends entirely on the movability of the sacro-iliac joints. During 
pregnancy the joints soften and allow much greater separation of 
their surfaces, without the rupture of the capsules. 

Indications — Principally pelvic contraction, and as a substitute 
for craniotomy on the living child, and Caesarean section from the 
relative indication. The limits are 7 to 8 cm. or 8^ cm. in a gen- 
erally contracted, or where the child seems very large. Very few 
operators allow a C. V. of less than 7 cm. The operation thus en- 
croaches on the field occupied by three other procedures : 

1st. Version and extraction. This should not be done in a 
pelvis of less than 8 cm., unless the child is known 
to be small. 
2nd. Craniotomy of the living child, as a primary operation. 
After labor has been in progress for some time and 
infection taken place, or the maternal tissues bruised 
and the child in poor condition, the outlook for sym- 
physiotomy is bad. 
3rd. Caesarean section under the relative indication as a 
primary operation. In the same conditions as just 
enumerated, the outlook for Caesarean section is bad 
and one, therefore, usually prefers craniotomy. 
If the w^oman should come to you during pregnancy, the question 
of the induction of premature labor comes up. The German school 
advises premature labor. Dr. Jaggard was also of this opinion. 
Pinard and the French school in general advise symphysiotomy. 
The maternal mortality of premature labor is about ^%. The 
mortality of the children is higher, fully 25% die either in labor or 
in the first few weeks after it. Decision is difficult and requires 
consideration of many conditions and much experience. 

Other indications for symphysiotomy are : Face presentations 
with the chin immovably posteriorly. This is not a rational proced- 
ure and has found very limited acceptance. 
Conditions — 

(i) Os dilated (for the subsequent extraction). 

(2) Pelvis not too contracted, not anchylotic at sacro-iliac 

joint. If less than 6 7-10 cm. no outlook for a good 
result, either for mother or child. 

(3) If the bag of waters is not ruptured it is better. 

(4) Child must be living and in good condition. 

(5) Mother must be in good condition, not infected. 
Preparations — Same as for any serious operation. Need at least 

three assistants. One for each leg, one for anesthetic. If possible, 
have some one who will deliver the child while you attend to the 
operation. This is to avoid having the same hands getting into 



432 NOTES ON OBSTETRICS—SENIOR CLASS. 

the wound that go in the vagina. May use gloves for this part of the 
work, or use two pairs. Pubis shaved and abdomen with upper part 
of thighs scrubbed with soap and hot water, then alcohol, then bi- 
chloride I :i,ooo; cover with a towel wrung out of bichloride while 
making the other preparations. Vulva scrubbed likewise. Vaginal 
douche and scrubbing with i% lysol, which must include the cervix. 

An accurate diagnosis of the pelvis, of the presentation and 
position. Examine the pubis, its thickness and the position of the 
clitoris and urethra, so as to be able to avoid them during the oper- 
ation. 

Operation — Incision in the median line, from a little above the 
pubis down to within a cm. of the clitoris, oi¥ to the left side of 
this. Bare the bone ; finger from above goes behind the joint, push- 
ing up the head if necessary. With a strong scalpel the joint is 
opened from before backward, the finger preventing injury of the 
bladder. The' assistant holds the bladder to the side with a catheter. 
The legs are held tight, or the pelvis supported so that the opening 
of the joint be not too sudden. There is a characteristic noise as 
the joint opens. Now hemorrhage occurs from the large venous 
plexuses around the urethra, vagina and bladder. May be controlled 
by packing with hot iodoform gauze. Allow the joint to separate 
6^ cm. to 7 cm. The deep perineal fascia is put on the stretch, 
as it passes between the pubic rami. Through it pass the urethra, 
corpora cavernosa, the vagina, large veins and plexuses. As the 
bones separate the fascia may tear. Results are hemorrhage and 
permanent injury to the structures, vesico-vaginal fistula, inconti- 
nence of urine. To avoid this try Harris' procedure. 

Fatal cases of hemorrhage from the veins are recorded and are 
often enough in this locality to make one very careful. Treat the 
hemorrhage by ligation, cautery, but best of all, by the packing with 
hot iodoform gauze. After hemorrhage has stopped, or before if 
necessary, deliver the child. If the head is engaged, forceps; if 
still movable, version and extraction. After head is in the pelvis, 
bring the ends of the pubic bones together by bringing the thighs 
together. This relaxes the stretched pelvic fascia and prevents tears 
of the vagina. Delivery as usual. Placenta expressed by Crede. 
If any perineal tears, they should be attended to. 

Now sterilize the hands again or new gloves, and remove the 
packing from the pubic w^ound ; hemorrhage almost always has 
ceased. See that nothing is caught between the ends of the pubic 
bones, while the assistants bring the thighs together and press the 
sides of the hips. 

Four sutures are passed, taking in fat and periosteum, silk, 
buried. Superficial silkgut sutures close the wound. No drainage 
necessary. Large occlusive dressing. Some accoucheurs use no 
deep sutures. 



NOTES ON OBSTETRICS—SENIOR CLASS. 433 

After Treatment — Of great importance. Tight pelvic band or 
girdle, adhesive straps. Absolute rest in bed. In a case of spon- 
taneous rupture of the pubis I used a square iron frame fitted with 
cloth straps and raised by pulleys in the ceiling, for bowel move- 
ments, urinations and dressings. Dressing changed if soiled. Pads 
changed frequently. No douches. See "Obstetrics for Nurses." 

Prognosis — Mortality in America has been 14%. In Europe 
that of certain operators has been less than 3%, but if all the cases 
were reckoned, no doubt there would be the same mortality as in 
America. Statistics thus are imreliable. For children, between 8 
and 15%. Not as good, by any means, as Caesarean section. Zwei- 
fel had 46 cases with 3 deaths. Later results are — 

(i) Sepsis, usually the operator's fault, but may be infected 
from infected genitalia. 

(2) Fistula. Not very rare. 

(3) Incontinence of urine. Generally transitory but some- 

times permanent, or present only when the patient 
stoops or lifts a heavy load. 

(4) Difficulty in walking. Pinard says it is a chimera. Ex- 

perience in Vienna not so favorable, still it is feared 
too much. 

(5) Subsequent conceptions and confinements usually nor- 

mal, but the patient may need symphysiotomy again. 
In a few cases pelvis was permanently enlarged. Re- 
minds one of Ollier's treatment, to do symphysiotomy 
in pregnancy, to avoid trouble in the coming labor. 
In general it may be said, do this serious operation only under 
the strictest indication. 

INDUCTION OF PREMATURE LABOR. 

This means the artificial induction of labor after the fetus is via- 
ble, but before term. The induction of abortion and premature labor 
has been done criminally from time immemorial, but the induction of 
premature labor for pelvic contraction is comparatively recent. The 
main indication is pelvic contraction, but there are several others. 
The first introduction of the operation is by Louise Bourgoise, mid- 
wife to Mary of Medicis, in 1608 (Pinard, Annal de Gyn., 1902). 
Conditions — 

1. Child must be living and viable. This must determine 
the time of the induction of premature labor. Before 
the 28th week there is very little outlook for a living 
child. Before the 32nd week the majority of children 
die, after the 32nd to the 36th the prognosis is good. 
But now the fetal skull is nearly as large as it is at 
term and little is gained. Best time is from the 32nd 



434 NOTES ON OBSTETRICS—SENIOR CLASS. 

to the 35th week. Further, the child must be living. 
If the fetus is dead this is a contra-indication to the 
induction of labor because it will occur itself in a few 
days. How to diagnose the time. Four methods : 

1. Menstruation. Count back 3 months and add 7 

days. 

2. Time of one coitus, 280 days from this date. 

3. Mensuration — pelvimeter, hand. Size of the 

child. 

4. Miiller's procedure — fitting head to pelvis. 

The time of the last menstruation is an uncertain 
guide and further, is not always known. The date 
of the impregnating coitus is usually unknown and 
when given allows only relatively exact deductions. 
The best guide is the mensuration of the fetal body, 
next to which comes IMiiller's procedure. We meas- 
ure the head and also the trunk. Cephalometry is a 
valuable addition to our knowledge, and with a little 
experience is easily practiced. One may use the 
cephalometer (of which that of Ferret is a good one) 
or an ordinarv pelvimeter. 

The head is grasped by the hands through the ab- 
dominal wall and while so held is measured. Know- 
ing the presentation and position we can judge in 
which diameter the head is measured and then deduce 
the others. Then it is sometimes possible to meas- 
ure the head through a vertical diameter by placing 
one blade of the calipers in the vagina. If it is a 
breech presentation it is usually easy to measure the 
head in the epigastrum. 

The length of the fetal body is gotten by putting 
one end of the pelvimeter on the breech and the other 
on the head through the vagina. Double this to get 
the length of the fetus, subtract two for the thickness 
of the walls, divide by five to get the month of gesta- 
tion. 

An experienced hand can guess the size of the fetus 
often within a few ounces and also judge the viability 
of the infant. 

^Miiller's procedure consists in forcing the head into 
the pelvis from without, at the end of each week from 
the 7th month on. When you find that the head will 
not enter the pelvis, induce labor. 

In a general way, the size of the uterus, the size 
of the mother, the history of large children, the fath- 
er's size, the hardness of the head, etc., give more or 



NOTES ON OBSTETRICS—SENIOR CLASS. 435 

less information. It requires much study of each case 
and much experience to guard against mistakes. The 
facihties for caring for the child afterward have 
something to do with it. One is encouraged to inter- 
fere earlier if incubators and o-ood nursing are to be 
had. 
II. The mother must be in good health, or relatively so. 
Do not induce labor on a dying woman. 

III. Degree of pelvic contraction not too great. Below 7 

cm. in a flat pelvis and 7^ in generally contracted, 
not safe to induce labor. Unless abortion is done in 
the early months, the patient must go to term and 
then Caesarean section or craniotomy on the living 
child. A C. V. of 7 cm. offers bad chances for the 
child, even if labor induced in the 32nd week. 

IV. Consent of the mother. 

V. Consultation. Fallacies of human judgment and the 
great responsibilities assumed, demand this. 
Indications — 

1. Contracted pelvis. 

2. Diseases w^hich are peculiar to pregnancy. 

3. Diseases which are accidental to pregnancy. 

4. Habitual death of the fetus after viability but before term 

(rare). 

I. Contracted Pelvis — 

In pelves from 7 to 8 cm. indication is for premature labor, to 
ayoid craniotomy on the living child, or Caesarean section, from 
the relative indication. Now symphysiotomy has encroached on 
this indication and has made the problem still more difficult. Pinard 
says that there is no more use for premature labor in contracted 
pelves, now that symphysiotomy is here. Some authors have advised 
to induce premature labor and then perform symphysiotomy also, in 
cases of absolute pelvic contraction, i. e., less than 6}^ cm., in order 
to avoid Caesarean section. The advice is not good because the mor- 
tality of symphysiotomy is high, with that of premature labor, very 
high, and the outlook for the child very bad. It must not be denieH 
that the prognosis for the child in premature labor for contracted 
pelvis is bad. Between the 32nd and 36th weeks the average bi-par- 
ietal diameter is 8 7-10 cm. From the 36th to the 40th week 8 9-10 
cm. About the 30th week it is 8 i-io cm. The gain therefore is 
small. 

The chances of compression in a pelvis 7 to 8 cm. are great, but 
the head is softer, usually, and more easily moulded. The best 
results are obtained when the contraction is from 8 to 9 cm., in cases 
where a craniotomy was done in a previous labor. But just this is 
the field claimed by symphysiotomy. 



43(5 NOTES ON OBSTETRICS—SENIOR CLASS. 

Other conditions must be considered: i. Exostoses. 2. Pelvic 
exudations, tumors,- especially retrocervical fibroids. 3. \'ery large 
child — patient has a history of large children. ]\lay sacrifice one 
child, premature labor on the next. 

One point to be considered ; that primiparae stand labor in a 
moderately contracted pelvis better than multiparae, because: i. 
Pains are stronger in primiparae. 2. Children generally smaller 
and softer. 3. Pathologic presentations not so common. 

If a woman has a contracted pelvis of 8 cm., two plans may be 
proposed — Caesarean section at term, and induced labor ; usually 
latter selected. If a woman has had craniotomy at term, she will 
usually demand premature labor in next pregnancy, but may be pre- 
vailed on to submit to Caesarean section at term, under ideal condi-' 
tions, as competent operator, good hospital facilities and nursing. 

2. Diseases Incident to Pregnancy — In which the life of the 
mother is endangered by the continuance of the condition. 

a. Eclampsia — Opinions are divided. Formerly, a purely 

expectant treatment till the attacks passed over, then in- 
duce labor or tide over to term. Then, all cases to be 
terminated at once.. Now a middle position is assumed, 
although the majority of accoucheurs advise the rapid 
termination of pregnancy but with more mild measures 
than were formerly employed. (See chapter on 
Eclampsia). 

b. Bright's Disease — When there is a progressive increase 

of dangerous symptoms, e. g., edema, dyspnea, uremic 
symptoms. If careful treatment has no effect, indica- 
tion is absolute. 

c. Placenta Previa — There is no expectant treatment for pla- 

centa previa. Remain by the patient till she is delivered 
and out of danger. Induce labor. Still, in some cases, 
when hemorrhage is insignificant and where patient is 
in a hospital, it may be possible to temporize. In gen- 
eral, the above rule holds good. 

d. Chorea — Aggravated by pregnancy, may be fatal ; prema- 

tui^e labor may occur spontaneously, nature showing 
the way to heal these cases. Still, premature labor does 
not cure all cases. 

e. Pernicious Anemia — Quite rare, and results not encourag- 

ing. 

f. Vomiting — The uncontrollable vomiting of pregnancy 

sometimes persists after the child is viable, but usually 
the question is whether or not to induce abortion. Same 
arguments as when the case comes earlier. 

g. Toxemia of Pregnancy — This may show itself as hyper- 

mesis or a state resembling typhoid. 



NOTES ON OBSTETRICS— SENIOR CLASS. 437 

3. Accidental Diseases — May endanger the life of the woman 
so that she dies before the termination of pregnancy. May be neces- 
sary to spare the woman the danger of labor or to avoid Caesarean 
section on the dead or moribund woman — e. g., Tuberculosis, Em- 
physema, Heart Disease ; Carcinomia Cervicis does not offer an indi- 
cation for premature labor. It is justifiable to do a Porro operation, 
or a complete extirpation of the uterus. Appendicitis no indication. 
Treat it as usual. 

4. Habitual Death of the Fetus After Viability but Before Term 
— It is hard to find the cause of death in these cases. But syphilis 
is most common. After this, Bright's disease, or profound anemia 
or other blood states or nutritional disorders. Finally, no cause 
may be determinable. This indication is legitimate, but there are 
two conditions : 

1. ]\Iust know the exact time in which the fetus generally 

dies. 

2. Must shut out syphilis. Treat the mother, she usually 

carries to term. 

This is a very difficult question to solve, and still harder to deter- 
mine upon inducing labor. 

Methods — A large number have been used, thus showing that 
they are both inefficient and dangerous. The oldest is probably 
the rupture of the bag of waters. At present three methods are in 
use, and the employment of each is goverened by the time at hand, 
and by individual preferences. 

1. Bougies — The use of bougies in the uterus. Krause's method. 
Rubber bougies, not catheters, about 16 English. Sterilize the vul- 
va, vagina and cervix. Sqap and water. Danger of carrying infec- 
tive material into the uterus. Bougies are sterilized by boiling. 
Passed in a speculum after most careful disinfection of the hands. 
Gloves. The bougie is passed to the side and behind, in the direction 
of the least resistance. Pass two, one to either side, till the end of 
the bougie rests on the posterior vaginal wall. 

Dangers of this method — (i) Sepsis; (2) Introduction of air;' 
(3) Placental site may be encroached on; (4) Bag of waters is fre- 
quently punctured; (5) Necrosis of the uterine wall in the path of 
the bougie. 

This method brings on labor in that the bougies acting as a for- 
eign body cause pains. Labor is natural, because the bag of waters 
is generally intact. Labor comes on in 24 hours in three-fourths 
of the cases ; but sometimes have to wait a week. Do not persist 
after 48 hours. A certain amount of separation of the membranes 
from the uterine wall takes place. This is one of the causes of the 
pains. 

2. Puncture of the ba§- cf waters (oldest method) — Puncture 
with a sound, over the internal os. \"arious instruments. Carl 



438 NOTES ON OBSTETRICS—SENIOR CLASS. 

Braun used a goose-quill. Pass any pointed instrument under 
cover of the finger. I generally use the scissors. Most effective 
method we have and there is no danger, but the objections are that it 
causes a dry labor. Cervix may be torn, head of the fetus suffers too 
much pressure, especially in primiparae. In multiparae no impor- 
tance. This method is to be preferred in cases of eclampsia, hydram- 
nion, heart disease, almost always in placenta previa. May be used 
to hasten labor in selected cases. 

3. Dilatation of the Cervix — This procedure is often used to 
hasten labor, but hydrostatic dilatation of the cervix is an effective 
method of inducing and completing labor. Barnes' bags in the cer- 
vix. Same precautions as before. Pass bag No. i first, then No. 
2, then No. 3. If labor in progress, wait. If not, may now do the 
operation known as intra-uterine colpeurysis. Carl Braun's bag 
placed in the lower uterine segment, then filled with- Davidson 
syringe. After filled may be dragged down. I often tise a small 
bag, shaped like a colpeurynter. They were formerly used for air 
pessaries. Traction of one pound. New instrument, Bag of 
Champetier de Ribes. More powerful than Carl Braun's. Not much 
better. Everything used in this procedure is to be sterilized by boil- 
ing, — Davidson syringe, bags, etc. 

This is an invaluable method and the cervix of even a primipara 
may often be so dilated in two hours as to enable delivery to be com- 
pleted, e. g., eclampsia, placenta previa. May be used as an aid to 
labor, or to the other methods. If cervix is rigid, bags not so 
efficient. 

Other Methods — Mentioned only to be condemned. 

(i) Trocar. Bag of waters punctured high up. Obsolete. 

(2) Intra-uterine injection of water, glycerine. Dangerous. 

(3) Kiwisch douche. Hot water against the cervix. Dangerous. 

(4) Colpeurynsis of the vagina. Inefficient alone. May be used 
as an aid to other treatment. 

(5) CO2, water irrigations of vagina. Fatal embolism. 

(6) Electricity. Inefficient alone, may aid other methods. 

(7) Irritants to breast. Unhandy, inefficient. 

Prognosis — Good. Not one should die from the operation. 
Sometimes die from the condition which indicated it. 

For the fetus, not so good ; 30% perish, but now, since the use 
of the incubator is known, better prognosis. Before the 32nd week 
the large majority of the children die. 

After this the prognosis improves as the time lengthens. The 
severity of the labor or the operation necessary to complete it, also 
the skill of the operator, have much to do with the results. 

It has been proposed to diet the mother to make the child smaller. 
Prochownik's plan of diet. Two cases in which the patient went to 
term and children were spontaneously delivered and lived, but al- 



NOTES ON OBSTETRICS—SENIOR CLASS. 439 

though well developed, were lean. Some women think that by limit- 
ing the salt-containing foods they make the children softer. 

ARTIFICIAL INDUCTION OF ABORTION. 

This operation is rarely indicated. It means the interruption of 
pregnancy before the 28th week. There are a few conditions which 
justify the operation. The conditions are similar to those for pre- 
mature labor, i. e., the woman must not be moribund. You must 
insist on council, consent of the mother and the husband. Avoiil 
the slightest appearance of mystery and secrecy. 

Indications — 

(i) Contracted pelvis below 6 cm. when patient refuses to allow 
the Caesarean section at term. Give woman the points. Give her 
the mortality rates. She will generally decide on abortion, but not 
always, the love of offspring being sometimes too strong. 

(2) Cases of incarceration of the retroflexed gravid uterus, 
when attempts at reposition have failed. Very rare. 

(3) Acute Hydramnion. Hydatidiform degeneration of the 
chorionic villi, when the diagnosis is made. Do not wait if there 
is any suspicion that the growth has become malignant. 

(4) The uncontrollable vomiting of pregnancy : Here there is 
great play for individual opinion. The numiber of cases needing this 
operation is decreasing, since we have better methods of treating the 
disease. If the case is seen early and if the diagnosis is made, the 
prognosis without abortion is good. The condition is sometimes 
given as an excuse for performing an abortion on a woman who 
wants no children. You will not be long in practice before you will 
be approached in a hundred different ways, to perform abortions. 
Not alone the single woman but also the married will come. The 
former are to be pitied, the latter are to be shamed. All argu- 
ments are brought to bear on you, — gold, disgrace, no more chil- 
dren, etc. Under no circumstances allow yourself to be influenced, 
because: (i) It is murder and your conscience will not rest; (2) 
It is a criminal offense; (3) If you do it on one, she will tell her 
friends and soon you will have the reputation of being an abor- 
tionist. These are not all of the reasons, but the first is enough 
alone. 

(5) Rapidly advancing tuberculosis; progressive heart disease; 
progressive renal disease (rare). 

(6) Hemorrhage — Persistent hemorrhage, sometimes due to a 
dead ovum, or to a tedious abortion or placenta previa, or to pla- 
centa marginata. Hemorrhage persists for weeks, and you have to 
step in, to save the woman's health. Seldom she will carry safely 
to term. 

Methods — Abortion is harder to induce than premature labor. It 



440 NOTES ON OBSTETRICS—SENIOR CLASS. 

is harder to procure complete separation of the membranes and 
placenta ; further, the uterine contractions are not regular. It is 
easier after the sixth month. In general, we may divide the cases 
into two kinds : ( i ) Where the operation is done during the first 
two months. (2) In the next four months. 

The methods that have been used are mechanical dilatation of 
the cervix with graduated bougies (Hegar's) or with Barnes' bags, 
or laminaria tents ; or, placing a flexible bougie in the uterus, after 
the method of Krause, 

In the first two months the best way to induce abortion is to 
dilate the cervix, cautiously, by means of Hegar's dilators, or by 
mechanical methods, glove-stretcher dilators, and scrape out the 
uterus, emptying it of its contents all in one sitting. Before the 
operation the vagina is thoroughly sterilized and after this the uterus 
is thoroughly douched with 1% lysol. As you have been clean it is 
not necessary to paint the mucosa with iodine or put in an iodoform 
pencil, or pack the uterus with gauze. I have but seldom seen hemor- 
rhage from an abortion after the uterus was completely emptied. 
If the cervix is rigid it is best to 'prepare it by tamponing for 24 
hours with 1% iodoform gauze. 

In cases from the 2nd to the 6th month, do the operation in two 
stages, unless there is urgent need for hurry. 

1st stage. Dilate cervix a little, pass one or two soft rubber 
bougies into uterus, pack lower part of uterus and cervix with weak 
iodoform gauze and vagina with sterile cotton. Wait 24 hours. 

2nd stage. Remove packing and bougies. Usually pains have 
expelled ovum, or inaugurated the abortion. If not, may repeat 
procedure or clean out uterus. Will find the cervix soft and dilated, 
or at least dilatable, so that it is possible to empty the uterus. In 
removing fetuses after the 3rd month, be careful to keep them whole ; 
a head floating in the uterus may require an hour to catch. If the 
fetus is removed piece-meal, collect the parts and assure yourself 
that the whole ovum has been obtained. Be sure whole placenta is 
removed, and curette uterus lightly with sharp curette, to remove 
thickened decidua. Beware of perforating the soft uterus. Use 
the Angers wherever possible and avoid instnunents. 

After Treatment — Rest for 10 days. Ext. Ergotae fl. and^ Ext. 
Hydrastis Canadensis fl. aa M x. t. i. d. No local treatment except- 
ing external douches. 

Prognosis — None should die from the operation itself. Not sel- 
dom patient will have a little fever if the treatment is prolonged, and 
it may extend over several days. A very disagreeable business, and 
one should make up his mind to do an abortion under compunction 
only. 

No internal medication is successful and safe to bring about the 
expulsion of the ovum., though many are advertised. After an abor- 



NOTES ON' OBSTETRICS— SENIOR CLASS. 441 

tion that has been treated properly and the uterus thoroughly scraped 
with the finger or curette, the mucosa is so much healthier that the 
next pregnancy is normal and the patient feels well. 

DISEASES OF THE PUERPERIUM. 

The puerperium, aside from minor disturbances, such as difficult 
urination, difficult lactation, is nowadays usually an uneventful con- 
valescence. The puerpera does not feel sick after the second day 
when the soreness is gone from the muscles and joints. 

The greatest danger that besets the lying-in woman is sepsis, 
either genital or mammary. Of course, a woman at this time may 
be seized with any of the general diseases, as typhoid, pneumonia, 
the exanthemata, etc., and these usually take on an aggravated 
course. They serve to render diagnosis difficult because many of 
the manifestations of sepsis are similar to theirs. 

Nowadays cases of infection during labor and the puerperium 
have diminished in frequency and severity, but they still exist and 
many more than there should be. 

Puerperal Infection — No subject in all obstetrics is more im- 
portant ; no branch of medicine imposes greater obligations than do 
the means for its prevention. 

Puerperal fever, or infection, or sepsis, must be the fear and 
the terror of the obstetrician. He must fear it as he does sin, and 
as he can prevent sin, so can he prevent puerperal fever, and he 
must not throw any responsibility where it does not belong. Puer- 
peral fever has been known as far back as medical literature ex- 
tends. Hippocrates mentions it, not under any name but the his- 
tories leave no doubt as to their nature. (See Adam's Translation 
on the Epidemics.) Celsus and Galen describe it, and all through 
the middle ages it was known and feared. 

The first lying-in hospital was established in Paris, and here 
the great obstetricians ]\Iauriceau, De la jMotte and Peu obtained 
their experience. Puerperal fever soon became epidemic in it, and 
Peu tells of it in 1664. 

In 1 750- 1 761 epidemics occurred in London in a private hospital. 
Edinburg had an epidemic in 1772, Berlin in 1778. 

The epidemics broke out as the material was used for instruction, 
especially of the students, and as the study of Anatomy became fa- 
cilitated by various states placing bodies at the disposal of colleges, 
the disease increased. 

In Paris the disease raged continually in the great Maternite, 
the mortality of cases confined being 9% in 1831. 

In Vienna, where the post-mortems were most carefully studied 
by the students under the great Rokitansky, the disease raged fear- 
fully. In 1823, the mortality was 20% of women confined and in 
1843 almost 16%. There were two or three post-mortems dailv on 



442 NOTES ON OBSTETRICS— SENIOR CLASS. 

puerperal fever cases, and the students went directly from the post- 
mortem room to the lying-in chamber. 

The disease was well known in England, and its contagiousness 
recognized. Denman was the first to point this out and it was 
customary there for a doctor with a run of fever cases to give up 
his obstetric practice for a certain time. 

The term puerperal fever is a misleading one, rather it leads to 
nothing. The pathology and bacteriology of infections post partum 
have undergone such rapid and radical changes in the last thirty 
years that the terminology could not keep pace with them. Thus 
the term puerperal fever has been retained. It was first used by 
Morton, in 1800. 

Few men have a succinct idea as to what puerperal fever really 
is. To some the term conveys the idea of a septicemia only, to others 
a fever specific to the puerperal woman, contagious like smallpox 
(Barker). There are many other conceptions of the disease. To 
start with, I wish to propose the following definition of puerperal 
fever. The term ''puerperal infection" is better, but the former term 
is older, and, if disassociated from the idea of an essential fever, 
and rightly understood, does very well. 

Deijuition — Puerperal fever, or puerperal infection, is a general 
term comprising all the conditions, usually of a febrile nature, but 
sometimes non-febrile, originating from infection of the genital tract 
at any point of its extent. 

It matters not whether the symptoms be mild, lasting but a few 
hours, or many days, whether there be a vulvitis or an endometritis, 
or a septicemia, whether one of the milder forms of saprophytic bac- 
teria, or the most virulent streptococcus be causative, whether the 
patient have fever or only a rapid pulse — if the complexus of symp- 
toms points to a genital infection the woman suffers from puerperal 
fever. This definition shuts out the miasmatic fevers, the essential 
infectious fevers, e. g., typhoid, diphtheria of the throat, erysipelas 
of all other portions of the body, but the genitals, etc., and since 
it includes many and widely differing clinical forms of disease, 
makes a careful classification of these forms necessary. This is not 
easy. 

With our present knowledge of bacteriolog}- and pathology it 
would seem inexplicable how this cause of puerperal fever should 
remain for so long beyond the reach of those able obstetricians from 
whose works we draw so much of our information in obstetrics. 
But there w^ere many difficulties in the way of investigation in those 
days, and again, only in the last one hundred and fifty years has 
obstetrics been in the hands of physicians. 

Up to the 17th Century the theory of Hippocrates was the gen- 
erally accepted one. He ascribed the disease to suppression of the 
lochia, taking an effect for the cause. Celsus and Galen accepted 



NOTES ON OBSTETRICS—SENIOR CLASS. 443 

this theory. The belief was that the lochia represented poisonous 
substances, which must be gotten rid of. If by a cold, fright, etc., 
they stopped, they were absorbed into the blood and thus caused 
puerperal fever. 

Puzos, of France, and many after him believed the milk theory. 
During pregnancy the milk secretion begins, but it is all determined 
to the uterus where the fetus uses it for nourishment. After labor 
it is excreted by the breasts. If by catching a cold, etc., the secretion 
should be stopped, so-called milk metastases occur and cause fever. 
Again, mixing cause and effect. Then the milk appears in the lochia 
(the purulent lochia of sepsis), in the peritoneal cavity (the pus of 
puerperal peritonitis), in the pleurae (pus from pleuritis), or in the 
joints (pyemic arthritis). Chemists even claimed to have made but- 
ter from the exudate in the peritoneal cavity, one saying he had found 
sour milk and butter under the skin of a woman dead of puerperal 
fever. 

At the end of the i8th century, when post-mortem examinations 
became more frequent, the so-called Anatomical Theory became 
known. This came a step nearer the truth. Puerperal fever then 
meant peritonitis. This being the lesion most often found. Soon 
another form became known, in which the veins were affected ; 
wherefore, phlebitis, etc. In 1830, Tonnele, of France, showed that 
in the majority of cases the lymphatics were involved, wherefore 
lymphangitis. This point is still accepted as true, but, according 
to Virchow, in another way. 

At this time Louis was making his researches on typhoid fever, 
and the various infectious diseases, as we now know them, were 
being assigned to their places in a new terminology. So it is not 
surprising that a certain group of symptoms were ascribed to puer- 
peral fever, and it came to be regarded by some as a specific dis- 
ease. Cruveilhier said it was somewhat like typhoid, while the es- 
sentialistes, as they were called in France, among whom are the 
names of Dubois, Depaul, Litzman, INIichaelis, said it was due to a 
miasm and was a specific contagious process propagable through the 
air and governed by telluric, cosmic and atmospheric influences, etc. 
Some called it a sort of putrid fever. 

In 1847 Semmelweiss, a young assistant in the clinic in Vienna, 
which was later occupied by Carl Braun, published his researches 
in a paper called, ''The Causation, the Definition and the Prophylaxis 
of Puerperal Fever," a paper wdiich has become classic and which is 
a monument to his name for all time. 

He announced that puerperal fever is caused by the absorption 
into the blood from the genitals of cadaveric poisons of any kind ; 
that the hands or any article brought into the genitals may be the car- 
riers of same. He did not come upon this by accident, but it was 
the result of vears of hard work and studv. He noticed that the 



444 NOTES ON OBSTETRICS—SENIOR CLASS. 

division of the clinic which was used for the instruction of midwives 
had a 3 3-10% mortahty from puerperal fever, while that for doc- 
tors had 9 9-10%, and that the children were affected with sepsis 
proportionately also. The personnel of the hospital observed this 
also and regarded the doctors with aversion. He could not explain 
this by any atmospheric or telluric influences. He observed that 
women that were delivered before reaching the hospital almost never 
took sick. 

He figured for years on these and many other similar facts 
until finally the death of his friend, Prof. KoUetschka, gave him 
the information. KoUetschka had infected his finger tip, at a post- 
mortem on a puerperal case and died of sepsis. The post-mortem 
of KoUetschka struck Semmelweis by its similarity with those he had 
made on puerperal fever cases. The explanation of puerperal fever 
was then clear. Particles of cadaveric decomposition were carried 
into the puerperal wounds and there caused puerperal fever. 

With the cause he sought the remedy. He instituted washing of 
the hands with chlorine water and later with chloride of lime solu- 
tion. Result dazzling. Mortality sank to 1.27%. Later an incident, 
rather an accident, showed him that any decomposing animal matter 
can be causative. 

Thirteen women lying in adjacent beds were examined in suc- 
cession by the assistant and staff. The first was a case of carcinoma 
cervicis uteri, the rest normal cases — the twelve women died of 
puerperal fever. 

Experimentally he introduced pus, ichor, etc., into the vaginae of 
puerperal rabbits. Death in all cases. 

So that this theory was proved and after many years was accepted 
and is accepted to-day — that puerperal fever is caused by decompos- 
ing animal organic matter brought from without into the genitalia 
and there absorbed. He did not live to see his theories accepted. 
About i860 signs of dementia appeared and he died later in an insane 
asylum. 

Pasteur, Widal, Robert Koch, now came and the Germ Theory 
of Disease was born. Then Lister came and in the seventies the 
full importance of Semrnelweiss' work was recognized. The reason 
for this delay is partly in the times, partly in the action of Semmel- 
weiss himself, for he made numerous open attacks on the professors 
of obstetrics during the insanity which was darkening his horizon. 

To an obstetrician, then, is due the credit of pointing the correct 
way to modern antisepsis and asepsis. 

The contagiousness of puerperal fever was known before Sem- 
melweiss' publication. Denman, in England, wrote of it. Dr. O. 
W. Holmes, in Boston, in his paper in 1843, Puerperal Fever a Pri- 
vate Pestilence, recognized the cause when he laid down these 
rules : 



NOTES ON OBSTETRICS—SENIOR CLASS. 445 

"i. A physician holding himself in readiness to attend cases 
of midwifery should never take any active part in the 
post-mortem examination of puerperal fever cases. 

"2. A physician present at such post-mortems should use 
thorough ablution, change every article of dress and 
allow 24 hours or more to elapse before attending a case 
of midwifery. 
"3.- Similar precautions should be taken after the autopsy or 
surgical treatment of cases of erysipelas, if the doctor 
is obliged to unite such duties with his obstetrical work, 
which is in the highest degree inexpedient." 

To Dr. O. W. Holmes is due the credit of having promulgated 
this doctrine and preparing the way for Semmelweiss. 

Since 1870 the history of puerperal fever has been the same as 
that of Listerism. Whereas at first women were delivered under 
the spray, later the most careful antisepsis of hands, vagina, etc., 
was practiced. Now a more aseptic technique is being adopted. 
One Russian author even wished his patients delivered in an anti- 
septic bath. 

Etiology — There is no one but admits that puerperal infection 
is caused by the action of living ferments, i. e., germs. These are 
usually introduced at the time of labor, but there are cases where 
infection occurs from germs present in the genital tract or nearby, 
before labor. This is rare, but its occurrence is no longer doubtful. 

Puerperal fever, or puerperal infection, is nothing more or less 
than an infectious wound disease. The sources of infection are 
menacing any open wound, plus those formed by the anatomical 
construction an^ the functions of the parturient canal. 

After labor the whole genital tract is a wound surface. The pla- 
cental site has open sinuses, veins, and there are always abrasions, 
tears and bruises of the cervix, vagina and vulva. These may be 
easily infected by germs carried in from without the patient, from 
germs carried into the w^ounds from the vagina, from germs carried 
into the vagina and the wounds from the rectum, or the skin 
around the vulva. 

The vagina of a healthy woman before labor contains no mark- 
edly pathogenic micro-organisms. Doederlein distinguishes two 
forms of vaginal secretion — normal, which is white, like curdled 
milk, acid, no mucus, small in amount; and pathologic, which is thick 
yellowish of greenish mucus, sometimes, foamy, alkaline usually, but 
not necessarily, and contains numerous pathogenic and non-patho- 
genic micro-organisms, whereas the normal vaginal secretion con- 
tains only the bacillus vaginag, a harmless organism. 

The cervix, above its middle, and the uterine cavity, according 
to the 'recent researches of Winter, Menge and Walthard, are ster- 



446 NOTES ON OBSTETRICS—SENIOR CLASS. 

ile. Some cases even where the women are apparently healthy, bac- 
teria are present. 

Kronig denies the statements of Doederlein. He says he could get 
no pathologic results with the bacteria he found in the vaginae. 
One of the most recent works on the subject is by Walthard, and he 
finds 2y% of the vaginae of his cases contained pathologic bacteria, 
which could be made virulent by proper culture. These statements 
are hard to reconcile with our clinical experience. 

We cannot go any further into this study, but the general result 
of all the investigators seems to be that although the vagina does 
sometimes contain pathogenic bacteria, they require special condi- 
tions to become virulent. 

What bearing has this on the question of self-infection? Of 
course if the vagina contains infective germs, after labor they may 
get into the puerperal wounds and cause puerperal fever without any- 
body having even touched the woman. 

Ahlfeld is the most ardent exponent of this theory, but the 
weight of clinical experience is against it. As far as we are con- 
cerned we will regard the genital tract as practically sterile, consider- 
ing the vastly greater danger as coming from without and give the 
role of infection from bacteria which may have existed in the vagina 
a very subordinate place. 

How are the bacteria which get into the vagina gotten rid of or 
made less virulent? 

Various theories, ist, Doederlein. Bacillus Vaginae produces 
lactic acid which makes a pabulum unsuitable for their growth. 
Denied by Walthard. 

2nd. Phagocytosis going on in cervix and vagina — Menge. 

3rd. During labor liquor amnii possesses antiseptic properties. 

4th. The passage of the child, secundines and blood scour out 
the parts. During puerperium the current of the lochia and the 
mucus covering the cervix which the lochia cannot dissolve prevent 
infection — Walthard. 

So we believe that the vagina has the power of self-disinfection 
to a certain extent and this prevents infection. 

This antiseptic power of the vagina is generally believed to be 
in abeyance during labor, so that other safeguards must be relied 
on, the most important of which is the antiseptic and aseptic conduct 
of the labor. 

BACTERIOLOGY. 

Up to the present time the follow^ing microbes have been proven 
causative of puerperal fever : 

I. Saprogenic bacteria, of which Rosenbach has made a par- 
ticular study. 



NOTES ON OBSTETRICS-SENIOR CLASS. 447 

2. Streptococcus pyogenes. Rosenbach, Pasteur, Doleris, 

Widal, 1879. 94% ^^ severe cases. 

3. Staphylococcus aureus, and albus. Haegler. 

4. Gonococcus of Neisser. 

5. Bacillus coli communis. Gebhard. 

6. Bacillus fetidus. 

7. Bacillus pyocyaneus. 

8. Bacterium aerogenes capsulatus. 

9. Pneumococcus. Fraenkel. 

10. Bacillus of diphtheria. 

11. Bacillus of tetanus. Nicolaier. 

12. Streptococcus erysipelatosus. Fehleisen. The identity of 

this germ with the streptococcus pyogenes has been 
about established. 

13. Bacillus typhosus. Blumer. Williams. 

14. Bacillus tuberculosis. Clinical. 

Several of these affect certain portions of the genital tract and 
under certain conditions only, others produce changes at any part of 
the tract where deposited, and the pathologic findings and symptoms 
vary with the part affected. With all we may have mild and severe 
infection, which depends not alone on the location and method of 
dissemination of the bacteria, but also on the idiosyncrasy of the 
patient, some women seeming to possess an immunity, others a pre- 
disposition to certain microbic infections. A careful study should 
be made to determine the bacterium causing the disease in each case, 
and as our efforts become more successful in this line we may expect 
more rational and successful methods of treatment. 

SOURCES OF INFECTION. 

These are many and are divided into two kinds : 

1. Those entirely from without the patient. 

2. Those from within the patient. 

The most common source of infection is the physician. He 
brings an infected finger, instrument or other foreign body into 
the genitalia. This infection he has carried from a case of puerperal 
sepsis, from dressing an ulcer, or from any suppurating or infected 
surface. Other sources from which infection may be carried are 
post-mortems, erysipelas, cancer, lochia, even of normal puerpera, 
diphtheria, scarlatina, typhoid, pneumonia, ozena, and even the 
ordinary filth under the finger nails. The nurse may infect the 
patient in the same manner. In addition, the menstrual blood is in- 
fectious. 

The patient has certain sources of infection herself. The vagina 
may not be aseptic at the time of labor, e. g., coitus may have been 
recent ; the patient may have examined herself. The rectum is close 



448 NOTES ON OBSTETRICS—SENIOR CLASS. 

by and contains the colon bacillus. The bladder is sometimes in- 
fected. The vulva is never sterile. The patient may have a suppur- 
ating focus in some distant part of the body, e. g., an artificial eye, 
erysipelas, tuberculosis with secondary infection, a felon, etc. The 
physician may infect the patient by carrying these infections into the 
puerperal wounds, or the patient may carry them there herself, or 
in rare instances they may invade the genital tract themselves, by 
way of the blood stream. 

The number of cases referable to this form of infection is very 
small, compared with those where the poison is introduced directly 
by the physician from without, so that much responsibility rests on 
the accoucheur in the prevention of child-bed fever. 

Prophylaxis — Much can be accomplished in prevention as com- 
pared with the little by treatment of infection. In general the same 
principles are applicable here as in the care of any surgical opera- 
tion. I. Limit as far as possible the puerperal zvoiinds. IL Prevent 
the infection of the necessary puerperal wounds. 

(I) I. General Rule — Interfere as little as possible in the course 

of labor. Operate only under urgent necessity. 

2. Make vaginal examinations few, hardly ever more than 

two for a normal case. Make diagnosis of presenta- 
tion and position of fetus by abdominal palpation. 
Gently do the internal examination, which must be 
short. 

3. Let the bag of waters rupture spontaneously, because: 

(a) The child is in little danger of asphyxia while it is 

intact. 

(b) Nothing dilates the cervix with less trauma, hence 

little tearing. 

(c) Mechanically prevents the access of air, with germs, 

4. Do not give ergot during labor. Instruments more often 

necessary. 

5. Avoid all practice to cut short the length of labor, e. g., 

dilation of os of the perineum. 

6. Express placenta by Crede method. Keep hand out of 

uterus post-partum as much as possible. Conduct third 
stage so as to leave no membrane or clots in uterus and 
vagina. 

(II) One must consider — 

1. The operator and nurse. 

2. The patient. 

3. The paraphernalia. 

4. The environment. 

The Operator — Clothes should be clean, no contact with post- 
mortem tables, pus basins, etc. Bathe frequently and shampoo, 



NOTES ON OBSTETRICS—SENIOR CLASS. 449 

beard and head often. Always have clean finger nails and hands. 
A general cleanly appearance invites the confidence of your more 
intelligent patients. Scrupulously avoid touching infective material! 

Method of Preparing Hands for Obstetric Cases — 

General Rules — 

1. Keep the hands aseptic as far as possible by avoiding direct 
contact with infective matter of all kinds. Use rubber gloves when 
treating infected cases. 

2. After all dissections, dressing pus cases or erysipelas cases, 
or touching the lochia of puerperal cases, sterilize the hands. 

3. After attending diphtheria or scarlet fever cases, etc., change 
clothing, bath, shampoo head and beard. 

Sterilizing the Hands, and the Obstetric Examination — 

1. Coat off, sleeves above the elbow for all cases. 

2. Scrub in running water or frequent changes for five minutes. 
Rinse and dry. 

3. Now pare and clean the finger nails carefully. 

4. Wash for one minute in hot water; dry the hands and make 
the external examination. After this — 

5. Get two solutions ready, near the bed : 

(I) 1 :2,cxx> bichloride. 
(II) 1 : 1,000 bichloride or 1% Lysol. 

6. Now scrub for five (5) minutes in running water, paying at- 
tention to the creases and under the finger nails. 

7. Wash the vulva with solution No. I, leaving a bit of soaked 
cotton in the vulva. (Patient has already been once prepared.) 

8. Now scrub in the solution No. II for a full minute and carry 
the two first fingers, still wet with the solution, directly into the 
vulva, being sure that they touch nothing on the way. 

After having to do with septic cases, double the time of each pro- 
cedure and wash the hands with alcohol just before point 8. Use 
sterile rubber gloves. 

The accoucheur should wear a gown and cover head and beard. 
Rubber gloves are a valuable aid in our prevention. 

The Patient — Should bathe frequently in the last months of preg- 
nancy. Before labor she should take a general scrub bath, paying 
particular attention to the genitals, with soap and water, and then go 
over the hip region with i :2,ooo bichloride, giving special care to 
the vulva. The vulvar hair should be clipped. 

If you find a vaginitis granulosa in pregnancy use i :2,ooo per- 
manganate douches, ichthyol gauze and before labor a 1% Lysol 
douche. 

The Paraphernaliar — All instruments, cotton, gauze, etc., that 
comes near the patient must be sterilized. Instruments must be 
boiled five (5) minutes in 1% soda, with lid on. Catheters and 
douche points boiled and passed by sight. Water for douches, etc., 



450 NOTES ON OBSTETRICS—SENIOR CLASS. 

must be boiled and cooled. If obliged to use from tap always use 
an antiseptic to sterilize it, allowing plenty of time for same. 

The Environment — ^Of least importance. It is nice to have a 
clean bed and clean room to work in, but not absolutely necessary. 
If the doctor has mastered the principles of asepsis he can confine 
a patient on a door mat and have no fever. The work in the Chi- 
cago Lying-in Hospital Dispensary has proven it. Lay down this 
law. If you sterilize the vulva and sterilize the finger, and every 
instrument, etc., going into the vagina, you need never worry about 
getting a case of puerperal fever.. 

CLASSIFICATION OF PUERPERAL INFECTIONS. 

Puerperal infection is a protean disease. There are mild and 
severe cases, local and general infections, many kinds of germs 
causative, and women react differently to them, so that the clinical 
pictures are exceedingly complex and one can seldom arrive at a 
perfect diagnosis. 

A classification founded on the bacteriology, a biological or botan- 
ical classification, would certainly be most scientific. While, no 
doubt, many microbes produce distinct clinical pictures, too large a 
number produce similar symptoms, or are intermingled, to allow the 
clinical use of a classification based upon bacteriologic investigation 
of the discharges, blood, etc. Further, one microbe may produce 
differing clinical forms of disease. We can often in given cases say 
this or that microbe is causative, but this forms at present an uncer- 
tain guide to the treatment. Examples of this are diphtheria, the 
streptococcus and lately the staphylococcus, and the tetanus bacillus. 

The streptococcus causes 9-ioths of the severe infections, yet 
sometimes a patient will run a mild fever with this germ. The 
staphylococcus aureus is sometimes mild, sometimes severe, in its 
effects. If, for example, the streptococcus is associated with the 
bacillus coli communis, a very virulent type of disease will result — 
and so on. 

Another classification is that based on anatomic-pathologic find- 
ings, and which divides the cases strictly according to the parts in- 
volved. Thus there is vulvitis, vaginitis, endometritis, parametritis, 
perimetritis, metrophlebitis, etc. Clinically, this is better, but not all 
the forms of puerperal fever are localized to the sites at which the 
infection enters — a general sepsis may occur from a frenulum tear, 
and any of the germs mentioned may gain entrance at any place in 
the genitals and produce various and complicated symptom-com- 
plexes, and further the simple knowledge of the site of the disease 
is not a sufficient guide to a rational treatment. To say, for example, 
that a woman has endometritis is by no means enough. 

Finally, the clinical classification must be considered. This di- 



NOTES ON OBSTETRICS—SENIOR CLASS. 451 

vides the whole group of symptoms into three grand classes — first, 
sapremia ; second, septicemia ; third, pyemia. 

Sapremia means the absorption into the blood from a focus of 
decomposition, of the products of germ activity, i. e., it is a septic 
intoxication. Though the term is limited to the saprophytic infec- 
tions, the intoxication from pus located in the genitals may come un- 
der this head. 

This is a very convenient term to use for that class of cases 
where a decomposing blood-clot, or piece of placenta, or pent-up 
lochia, in the uterus or vagina, give rise to fever, which disappears 
when the cause is removed. 

Septicemia means the absorption into the blood of living fer- 
ments — germs — which, multiplying there, produce death by the tox- 
ines produced. Any local infection can be the starting point of a gen- 
eral septicemia. It cannot be doubted that in all local infections 
some germs get into and are killed in the blood. 

Pyemia really is a septicemia. It means literally pus in the 
blood, but is used to describe those cases where infected emboli start 
from a iocus of suppuration and, becoming lodged in distant or- 
gans, start up new foci of suppuration. 

Now these three forms almost never exist alone, but are more 
or less combined. Saprogenic bacteria develop with the virulent 
streptococcus, and the former may, by weakening the barriers put 
up by nature, prepare the way for an invasion by the chain coccus. 
The staphylococcus may produce a local inflammation from which 
toxines are absorbed, producing chill, fever, etc. — this is septic intox- 
ication. Should the blood be finally invaded the symptoms aggravate 
— this is septicemia or septic infection. The clinical pictures thus 
produced are often indistinct, requiring acute observation and clini- 
cal experience to distinguish between them. 

The saprophytes do not multiply in the blood, they live on dead 
and necrosing tissue ; thus they may exist on the sloughs caused by 
the pus germs. If they cause death it is by the ptomaines absorbed. 

The pus germs, particularly the streptococcus, are ubiquitous, 
acting in three ways — first, as a purely local rapidly healing process, 
with mild, general symptoms ; second, as an acute general infec- 
tion, usually fatal ; and third, as a more chronic disease under the 
picture of a pyemia with metastatic abscesses and inflammation. In 
addition to all these we have the clinical forms of tetanus, erysipe- 
las, diphtheria, gonorrhea, etc. 

Now out of this chaos is it possible to evolve a single classification 
which shall cover all the cases and be a working guide to the treat- 
ment? It is not possible, and I do not think it is desirable at present. 

Crede divides the cases into local and general, which is conven- 
ient from the standpoint of treatment and prognosis. 

No single classification will cover all the conditions. We need all 



452 NOTES ON OBSTETRICS—SENIOR CEASS. 

three and in practice the diagnosis will have to comprehend an un- 
derstanding of — 

( 1 ) The site of the infection and its course. 

(2) The extent of the infection, whether purely local or al- 

ready general. 

(3) The kind and the virulence of the germ that is causa- 

tive. 
To get all this information requires — 

(i) An intimate knowledge of the clinical pictures produced 
by each germ, in all variations of virulence and of 
site of infection. 

(2) A study of the case by examination of the patient, the 

discharges, the blood, etc. 

(3) Intelligent observance of the progress of the disease. 
Thus our diagnosis will run as follows : 

Sapremia, or septic intoxication, due to vulvitis, or decomposing 
decidua, or lochiometra or lochiocolpos. 

Septic intoxication, from an endo- or parametritis. 

Parametritis and septicemia, from infection of a cervix tear with 
the streptococcus. 

Endometritis, septicemia, pyemia, due to pus germs. 

Endometritis, peritonitis, streptococcus of erysipelas. 

Diphtheritic vaginitis, Loeffler's bacillus — and so on. 

Clinical Forms of Puerperal Infection — We distinguish the fol- 
lowing types of infection which are fairly constant, though new and 
unusual forms appear frequently : 

1. Vulvitis and colpitis. 

2. Endometritis, mild and malignant. 

3. Fever, etc., from pent-up lochia, in uterus or vagina, from 

infected material in the uterus or the vagina. 
Sapremia, which is cured by removal of the offending ma- 
terial. 

4. Parametritis. 

5. Peritonitis, local and general. 

6. True septicemia. (So-called ''puerperal fever.") 

7. Septico-pyemia. (^letro-phlebitis.) 

8. Septic endocarditis. 

9. Phlegmasia alba dolens. 

Many symptoms are common to all of these conditions and the 
diseases are often combined. 

Vulvitis — More or less severe inflammation of the vulva. Edema, 
redness ; the little puerperal wounds are covered with gray exudate, 
with red edges (puerperal ulcers), with purulent discharge; non- 
union of perineorrhaphy — pus. 

Causes — Traumatism during labor and infection. Pre-existing 
vaginal or vulvar infection (e. g., bartholinitis). 



NOTES ON OBSTETRICS—SENIOR CLASS. 453 

Symptoms — Usually slight if there is drainage. Temperature 
loo-ioi. Pulse 80-100. Patient complains of burning in urination, 
sense of heat and slight pain locally. If a perineorraphy done which 
is infected, the symptoms may be severe ; high fever — 104, high pulse 
— 120, chill, malaise, etc. These usually subside after removal of the 
sutures, but sometimes a general sepsis results. 

Treatment — Remove all sutures at once. See that drainage is 
good and touch all the wounds with Tr. Iodine. Then douche the 
external parts with some antiseptic solution every four hours. For 
pain during urination and distress, hot applications of liq. plumbi 
subacetatis. 

Vaginitis — The same findings as in vulvitis, but there is more 
swelling, more purulent secretion. The puerperal ulcers are found 
and if the streptococcus is present they are covered with a diphthe- 
roid exudate. The lymphatic are swollen and the neighborhood of 
the vagina infiltrated. 

Causes — Traumatism during labor. Too many examinations, 
long labor, forceps operation, hot douches, prolonged use of the 
colpeurynter, tamponade, especially strongly antiseptic gauze — all 
these plus infection, which, of course, is thereby favored. It is 
remarkable, the recuperative power of the vagina after injury if 
there is no infection. Sometimes diphtheria of the vagina. 

Symptoms — The same as vulvitis but more severe. Temperature 
higher, 103, pulse no to 120, both depending on the kind and viru- 
lence of the causative germ. 

If the drainage is free symptoms milder, if not, the condition is 
called lochiocolpos, and general symptoms severe until condition is 
reUeved. 

Treatment — Remove sutures if there are any, and touch puer- 
peral w^ounds with Tr. lodi. Then leave the patient alone, as long 
as drainage is free. No douches because they may carry the infec- 
tion higher, and they can do little good in combatting the germs in 
the tissues. 

Keep bowels free. Keep the patient quiet. Give ergot M. xv 
t. i. d. Give urotropine gr. v t. i. d., if there are any bladder 
svmptoms. Light but generous diet, and patient will usually get 
well. 

ENDO]\IETRITIS. 

This is the most common form of infection, although seldom oc- 
curing alone — but often combined with colpitis or metritis. Very 
few infections without it. 

Predisposing Causes— 

(i) Endometritis during pregnancy. That a microbic endo- 
metritis can occur during pregnancy there are cases to show. 



454 NOTES ON OBSTETRICS—SENIOR CLASS. 

(2) Infections of the endometrium before or during labor by 
examinations, bougies, colpeurynters and by gonorrhoea, or cases 
where liquor amnii is already decomposed in a long labor. 

(3) Retention of remains of decidua or the chorion or especially 
pieces of placenta or perhaps a blood clot. 

(4) Severe bruising of the lower uterine segment by operative 
procedure. 

How do germs get into the uterus ? 

1. By the fingers pushing the vaginal secretion into the uterus 
or directly placing new infection there. Same true of instruments, 
e. g., forceps. 

2. Entrance of air into the uterus during long labor and fre- 
quent and careless examinations. 

3. Relaxed uterus — stasis of lochia — germs can wander along 
surface — Rare. 

4. Shreds of membrane hanging down into the vagina can form 
bridges on which the germs get into the uterus. (Schroeder.) 

Now it must not be supposed that the presence of decidua or 
even a piece of placenta in utero means that it will cause an endo- 
metritis. The infection must also be present. Pieces of placenta 
can remain in the uterus for weeks without decomposing, till, after 
a careless examination, the infection begins. 

The importance of a well contracted uterus was recognized even 
in the olden time. A uterus that is relaxed absorbs very actively 
ptomaines produced in its interior, and again it allows them to ac- 
cumulate here. A well contracted uterus expels decomposing clots, 
secretions, etc., and in addition has less absorptive power. If the 
uterus becomes bent on itself at the cervix, especially after the 6th 
day, when the uterus being strongly anteverted may catch behind 
the symphysis, the lochia may be pent up in the uterus and a con- 
dition analogous to lochiocolpos results. It is more common than 
this and is called Lochiometra. It usually causes a severe chill 
and rise in temperature, which go down just as quickly if the cause 
is removed. 

Pathology of Endometritis — Mucous membrane red, swollen, 
softened, rugous, covered with necrotic decidua, secretion mucus or 
muco-purulent and hemorrhagic. Cervix also involved, is edematous, 
eroded — bloody, with increased secretion. 

Under the glandular layer is a bank of white blood corpuscles, 
forming a barrier against the germs which infiltrate the decidua. 
The saprophytic bacteria and the pus germs are here involved. 

Bumm — made bacteriologic and histologic study and found three 
forms of reactive inflammation : 

1. That due to infection with saprophytes, and is shown by the 
decomposing of the decidua. 

2. That due to infection of the decidua with pyogenic organ- 



NOTES ON OBSTETRICS-SENIOR CLASS. 455 

isms, but in which they are Hmited to the surface by the wall of 
granulation tissue. 

3. Same as No. 2, but the germs break through the wall and get 
into the spaces between the muscles. 

The endometrium becomes intensely infected and inflamed, — 
soft as paste, gray, greenish or black. Distinction of the structures 
of the parts is lost, or the surface may be covered wath a diphtheroid 
membrane (not true diphtheria), and in the speculum (which you 
must never use) shows the cervix eroded and covered with this 
croupous exudate. The uterus becomes edematous, involution ceases, 
the muscle relaxes and the ptomaines and germs find ready access 
to the blood. 

Or the endometrium may be cast off with a piece of the muscular 
substance forming a large slough, — the Metritis Dissecans of Gar- 
rigues. These changes are those of acute Septicemia, the considera- 
tion of which we wall have later. 

Symptoms of Endometritis — 

I. Subjective — Chill or chilly sensation with rise of temperature, 
on the 3rd, 4th or 5th day. Very little pain. Temperature goes to 
102-103. Pulse, loo-iio. Malaise, headache, feeling of heat, etc., 
are mild. Usually patient sleeps well, which is a very good sign, 
showing mild character of the disease. Milk secretion normal. Con- 
stipation often present. After pains are sometimes severe — an im- 
portant sign, as they usually have ceased by the 3rd day and the re- 
appearance is significant. Otherwise patient is not very sick. 

II. Objective — Lochia usually fetid, at first decreased, later in- 
creased in amount. Remain bloody longer, and may erode the vulva 
— because irritating. Uterus somewhat retarded in involution, 
softened and a little tender. In uncomplicated cases no tenderness 
to either side of the uterus or of the peritoneum. No tympany — 
abdominal walls not tense. Fever — has morning remissions of i^ 
degrees, and lasts from 4 to 10 days. Unless the process gets worse 
symptoms disappear in a few days. If the disease takes a bad turn, 
the general symptoms become grave, the patient immediately shows 
she is very sick. 

Treatment — The treatment of ordinary endometritis. At the first 
rise of temperature or chill that announces the infection, carefully 
examine the patient to see if you can determine any other cause for 
the fever. Here is where the question of "milk fever" comes up. 
As the milk begins about the 3rd day, a great many cases of tem- 
perature are referred to the breasts, when really an endometritis 
is at the bottom of it. I do not believe in "milk fever," — but we will 
consider that subject later — under mastitis. 

Exclude by careful examination all the causes for fever, e. g., 
general diseases, typhoid, pneumonia, angina, constipation, etc. By 
careful consideration of the symptoms you can usually arrive at a 



456 NOTES ON OBSTETRICS—SENIOR CLASS. 

sufficiently positive diagnosis to act on. (See treatment of next 
subject.) 

Fever from Retained Foreign Matter — Lochiocolpos and lochiom- 
etra have been referred to. They usually give rise to fever with 
symptoms more or less severe, depending on the nature of the in- 
fection, which disappears rapidly when drainage is established. 

When a puerpera develops fever, which, by exclusion, is found 
to come from the genitals, the first question that arises, is there 
anything in the uterus? If there is a piece of placenta, a clot, a 
mass of membranes in the uterus, the same may not become in- 
fected if the uterus is firmly contracted and if no infection is carried 
in from the outside. Should it become infected the symptoms are 
those of endometritis, of which there is more or less always. 

In most cases the infection remains local, the germs growing 
on the dead tissue and the absorbed toxines causing the symptoms. 
A large number of germs probably get into and are killed in the 
blood, but there is no invasion of the lymph and blood streams, as 
in septicemia. The danger of these infected, necrosing bodies, lies 
then in their providing a favorable nidus for the virulent strepto- 
coccus, in developing the virulence of weakened cocci, or the altera- 
tion of the subjacent mucosa, so that it offers less resistance to the 
micro-organisms present in the vagina, cervix and uterus. 

Diagnosis of material in the uterus — History of the labor. May 
know that the placenta and the membranes were not complete, that 
there is a blood clot in the uterus, e. g., hemorrhage post partum, 
which ceased gradually. If do not know, suspect under these condi- 
tions : 

1. Large soft uterus. 

2. Long continued and severe after-pains. 

3. Bloody lochia, and presence of clots in it. 

4. May feel them by examination. 

If in doubt, the case not being your own from the start, it is 
better usually to clean out the uterus anyway at the beginning of 
treatment. 

Sometimes the uterus will expel the putrid mass and the fever 
will at once disappear. We may wait for this if the case impresses 
us as a mild infection, but usually we cannot be assured that this 
is so, and we must know the uterus is empty. 

Treatment — When there are pieces of placenta, or masses of 
membranes or blood clots decomposing in the uterus and giving rise 
to septic symptoms, they must be removed. The preparations are 
the same as for any severe gynecological operation. The vagina 
is especially well cleansed with a lysol douche (1%). The uterus 
is also douched and then wdth the finger the whole uterine mucosa 
is cleaned off smoothly. i\fter this another lysol douche is given 
and a strand of iodoform gauze is left in the uterus for 5 hours. 



NOTES ON' OBSTETRICS—SENIOR CLASS. 457 

Give the patient ergot and hydrastis, ext. 11. aa M. x, q. i. d. ; 
put an ice-bag on the lower abdomen, keep bowels open with cascara 
and enemata. Give tonics, Tr. Nux. Vom. M. vi., q. i. d. ; baths for 
temperature. Water freely, light strong diet. 

Leave the uterus alone as long as there is good drainage. No 
douches or other local treatment except the external antiseptic 
douches to the vulva. 

Not seldom the manipulations in cleaning out the uterus are fol- 
lowed by a chill and a sharp rise in temperature, due to the flooding 
of the system with toxines, and the re-inoculation of the blood from 
the freshly abraded surfaces. In rare instances, a severe form of 
fever may result from the interference, but usually the temperature 
goes down very soon and stays nearer the normal, and recovery must 
be attributed to the emptying of the uterus. 

PARAMETRITIS. 

Another of the milder varieties of puerperal infection is para- 
metritis. Pelvic cellulitis is a better term, as the infection may 
gain entry to the cellular tissues not alone at the sides of the uterus 
but at any point from the vulva to the tubes. Lymphatic glands at 
base of broad ligaments sometimes enlarged. 

Cause — Is infection which gains entrance to the cellular tissue. 
All severe local infections are attended with some cellulitis, which, 
in malignant cases, arises by direct transmission through the uterus. 

In most cases the atrium of infection is a wound of the cervix, 
lower uterine segment, vagina, or perineum, — named in the order 
of freq^uency. 

The staphylococcus and the streptococcus are usually causative, 
though other germs have been found, e. g., the gonococcus. 

The connective tissue spaces at the side of the uterus are large 
and the planes of fascia many. The cellulitis is like cellulitis any- 
where else, first inflammatory edema, then white-celled infiltration. 
A tumor formed of inflammatory exudate forms at the side of the 
uterus. This exudate may extend to the walls of the pelvis and 
travels in several directions. 

1. It may expand the folds of the broad ligament and rise high 
in the abdomen. 

2. It may go to the side of the pelvis and get up into the 
iliac fossa. 

3. May go dow^n under the Poupart's ligament. 

4. It may extend up the infundibulo-pelvic ligament into the false 
pelvis, and along the psoas, in which event we must expect troubles 
due to involvement of the nerves of the lumbar plexus. 

5. It may extend anteriorly around the base of the bladder, 
parametritis anterior. 



458 NOTES ON OBSTETRICS-SENIOR CLASS. 

6. Posteriorly along the utero-sacral ligaments around the rec- 
tum. (Later strictura recti.) 

7. It may from here go up along the sacrum till it reaches 
the kidney. 

8. It may go down toward the perineum, around the vagina and 
finally reach the vulva ; or, 

9. Out of the sciatic notch. 

Depending on its location it displaces the uterus to one side or 
the other, and upon its extent will depend the condition of the parts. 
If there is extensive exudation the pelvis may seem to be filled with 
a hard, resisting medium, all contour of the uterus and adnexae be-' 
ing lost, and the vaginal fornices being depressed. It feels as if 
plaster of paris had been poured into the pelvis. 

The extension of the process depends on — 

1. The virulence of the germs involved. 

2. The number introduced. 

3. The general condition and resistance of the patient. 

4. The amount of local injury inflicted. 

5. The kind of treatment given. 

Where severe and brusque operations have been done in the 
passages, the infection is more liable to be severe. These exudations 
are gotten rid of in two ways : 

1. Resolution and Absorption. 

2. Suppuration. 

In the former case the exuded fluids are re-absorbed, the white 
blood corpuscles are broken up and removed by the leucocytes, or 
are changed into connective tissue, which leaves dense cicatricial 
thickenings to mark the site of the inflammation. These cicatrices 
distort the pelvic organs, both as regards position and shape, and 
function. The uterus is sometimes found drawn over to one side 
of the pelvis and moored here immovably ; or, it may be drawn up 
toward the sacrum by the shortening of the utero-sacral ligaments, 
Schultze's Anteversion. 

If the process ends by suppuration, there appear in various parts 
of the exudate necrotic areas and these become converted into pus. 
The whole exudate may become one abscess, or several, separated 
by septa. Thus, the whole pelvis may be riddled with abscesses. 
Depending on the location of the exudate and its proximity to one 
of the hollow organs of the pelvis, pointing will occur, and unless 
there is operative interference, in the course of twenty to seventy days 
the abscess will break into the rectum, vagina, bladder, ureter, skin 
or general peritoneal cavity. Then, if there be no other focus of 
suppuration the cavity closes rapidly. If there are other foci, these 
may undergo the same process and thus the patient may be sick with 
suppurating cavities for months and even years. 

These latter cases and the immense exudates extending to the 



NOTES ON OBSTETRICS—SENIOR CLASS. 459 

navel or kidney, are very rare nowadays, but in pre-antiseptic days 
they were common. The milder forms of parametritis, where the 
only relic of their existence is a little thickening in the fornices or in 
the uterine ligaments and displacement of the uterus, are very com- 
mon. Emmet, of N. Y., was the first to emphasize this frequency. 
According to Winckel, pelvic cellulitis suppurates in i8% of cases. 
That an inflammation of the pelvic connective tissue can exist with- 
out some involvement of the peritoneum, which is so near it, is not 
to be thought of, so pathologically we find the local serous surface 
inflamed, with the intestines matted together. In fact, it is some- 
times hard to say whether the peritonitis is primary or secondary. 

Symptoms of Parametritis — In the mildest forms, such as often 
are found during a gynecologic examination, as a thickening in one 
of the fornices, the symptoms during the puerperium are slight. A 
slight rise of temperature, a little local tenderness, or slight febrile 
symptoms, which are sometimes referred to something else (as "milk 
fever'), and the disease passes unnoticed. 

For the severer grades, however, there are marked signs of dis- 
ease. The symptoms usually begin on the 3rd,- or 4th, day. If the 
5th day has passed, according to Olshausen, there is little danger. 
Still, I have seen parametritis begin on the 8th or 9th day. These 
cases are called late fever, and are sometimes due to too early getting 
up — which starts up anew an unnoticed parametritis, or the move- 
ments tear open some small wound in the cervix, or, after some local 
treatment or examination, these wounds are reopened, and infection 
enters. 

Chill or chilliness, fever, 103-104. Pulse also goes up to loo-iio. 
Marked local pain and tenderness. Movement in bed is painful to 
patient. Coughing and sneezing painful. General symptoms of 
fever, e. g., headache, sleeplessness, anorexia, irritability, general 
tenderness. 

Locally, tenderness at either side of the uterus. Sometimes the 
uterus itself. Some tympany and tenderness of the abdominal wall. 
Internally (but you m.ust not examine), you would find the whole 
pelvis hot and soft, but at one point great tenderness and perhaps 
a well defined thickening or tumor, the exudation. Lochia usually 
fetid from concomitant endometritis or colpitis, but not necessarily. 

Sometimes the parametritis may be hidden under general symp- 
toms of sepsis. The fever is remittent in character and especially 
irregular if suppurations occur in the exudate. Then chills, fever 
and sweats occur — the patient passes into a condition called hectic, 
and unless the pus cavities open or are incised, the patient dies of 
exhaustion and sepsis, having wasted to a skeleton. 

If the abscesses open or are well drained, they heal rapidly, and 
if the patient's strength lasts they get well. 

If absorption of the exudate takes place the temperature grad- 



460 NOTES ON OBSTETRICS—SENIOR CLASS. 

ually goes down, the local symptoms disappear for the time, but 
later, symptoms referable to some pelvic displacement, make them- 
selves apparent and often the patient becomes an invalid for life. 

Resolution may require only ten days, while sometimes it may 
be sixty days, before the patient can safely get up. Bursting of 
a parametric abscess usually occurs after the fourth week. The 
severity oi the local process can generally be determined by the gen- 
eral symptoms, e. g., temperature and pulse — but not always, as 
sometimes a moderate amount of exudation causes severe symptoms, 
W'hile again a large exudate wdll occur with only mild manifestations 
of disease, sometimes none at all. You may examine these cases 
internally when you have reason to believe the inflammation is sharp- 
ly defined and the puerperal wounds cicatrized. 

Prognosis — Usually good. With proper treatment patient has a 
mild course of fever, and absorption of the exudate takes place. 
Even after the formation of an abscess prognosis as to life is good, 
as they either break or are incised and then heal. In the larger 
abscesses, prognosis guarded, as they sometimes suppurate for 
months, and the pelvis is riddled with sinuses and patient finally dies 
of hectic and exhaustion. 

Prognosis as to health is generally good, but only too often the 
women have backache, leucorrhea or disturbed pelvic circulation, — 
dysmenorrhea and symptoms of uterine displacements. The scars 
may contract and cause pressure on the nerves, neuralgias and paraly- 
sis, or on the ureters (w^hich the exudate may also do), and hydro- 
nephrosis, or traction on the bladder, and cause tenesmus, or the rec- 
tum m^y become strictured. The uterus is drawn to different parts 
of the pelvis and fixed, or it is w^alled up in exudate and atrophies. 

Treatment — Same as for perimetritis, and will be considered un- 
der that heading. 

PERIMETRITIS. 

This is an inflammation of the pelvic peritoneum. Inflammation, 
of the general peritoneum we will consider under the heading, sep-» 
ticemia, of w^hich it so often forms a large part. The fact that this 
is a localized peritonitis shows that w^e have to do with an infec- 
tion with germs of mild pathogenic power. Such is the case, for 
the germs found are sometimes the saprophytes, staphylococcus or 
the gonococcus. 

A peritonitis caused by the streptococcus is always dangerous. A 
slight infection may occur after considerable trauma, as w^here the 
w^alls of the uterus were strongly squeezed or torn. If the case is 
moderately clean we have local inflammation ; if infected, the inflam- 
mation extends over the Avhole peritoneum, and the course is rapidly 
fatal. 

Perimetritis, which, as you must understand, is the milder form 



NOTES ON OBSTETRICS—SENIOR CLASS. 461 

of peritonitis, develops therefore from : ( i ) Infection of the endo- 
metrium, which travels along the lymph vessels to the peritoneum, 
as was shown by Tonnele ; (2) a parametritis may develop from a 
torn cervix and the infection, without making any great changes in 
the broad ligaments, reaches the peritoneum, causing spread of the 
inflammation there; (3) the lower uterine segment may be com- 
pressed between the promontory and the fetal head, pressure necro- 
sis occurs, and if even a moderate infection is present, a peritonitis 
may start. The same is true of the ruptures of the lower uterine 
segment, if aseptic, the surfaces adhere by reactive inflammation. 
If a careless examination is made and the surfaces torn apart, an 
infection occurs, which is rapidly fatal ; (4) gonorrheal infection 
from a pus tube, which breaks during labor or from the end of which 
pus oozes out ; or gonorrhea may cause an endometritis or salpingitis 
and extend from the vagina and cervix to the peritoneum. These 
occur in the latter days of the puerperinm and a peritonitis develop- 
ing after the ninth day is almost always gonorrheal. (5) Fur- 
ther, the Bacillus Coli Communis is sometimes found. It w^anders 
through the intestinal walls when these have made adhesions and the 
wall is, therefore, diseased. Causative of peritonitis is Bac. Coli 
Com. by no means unless introduced from the vagina. 

The pathologic findings are such as are usual in these cases. The 
peritoneum is reddened, the surface lustreless, the bowels distended, 
adherent to each other, deep red streaks on them where the surfaces 
do not directly press on each other, and are covered with long strings 
of fibrino-pus, and serous exudate. Between the matted intestines 
a sero-pus is found in which float whitish yellow flakes of fibrin or 
the exudate may be all fibrin and pus. 

In the milder form^ these are the findings but in the severer cases 
the process extends over the whole peritoneum, whose surface is 
about equal in extent to that of the skin. The exudate may be 
tinged with blood, has a penetrating but not disagreeable odor, and 
may sting when the hand is immersed in it. The amount of exudate 
is generally small, but sometimes reaches two quarts if the patient 
lives long enough. 

It may be bound off by adhesions, making local collections of pus 
similar to those of parametritis, which may break into neighboring 
organs or creep further and may extend up to the diaphragm; the 
way being laid out by an advancing line of fresh adhesions which 
prevent general peritoneal infection. Care in palpating these cases, 
as rough pressure may cause these to rupture and make a general 
peritonitis. 

The usual location's for these collections of pus are in Douglas' 
cul de sac, and high up at each side of the uterus in the fold between 
the infundibulo-pelvic and broad ligaments. As they form when 
the uterus is in the abdomicn and become adherent at the level at 



462 NOTES ON OBSTETRICS—SENIOR CLASS. 

which they form, they do not sink with the uterus and therefore 
are found high up. This distinguishes them from parametritic exu- 
dates which are low, nearer the vagina. 

CoHrTse — The course of these exudates is the same as in para- 
metritis. I. Resolution and absorption ; II, suppuration and abscess. 
Latter more common than in parametritis. Former takes longer than 
in parametritis, and the organs are left more deformed and bound 
down or matted together. Frequently left gynecologic invalids and 
often sterile. 

If abscess 'forms it may break into the bowel, vagina or the 
bladder. There may be a series of abscesses which have to be in- 
cised. 

Symptoms — Patient almost always has a chill or chilly sensations. 
The symptoms begin almost always in the first y2 hours after labor, 
seldom later. Great local pain. Rise of temperature, which goes 
up steadily, reaching a point not as high as parametritis. The 
pulse goes up, however, rapidly and markedly. Even on the first 
day an increase in the pulse rate is notable, later is thready, or, as it 
is called, the peritonitis pulse. Patient has anorexia, nausea, some- 
times vomiting, usually constipation, great thirst, may be dysuria. 
Pain a prominent symptom. 

Objective Findings — Patient has suddenly become ill. The 
change in the lines of the face strike the observer. Nose pinched, 
eyes sunken, extremities cold. Pulse thready, running. Abdo- 
men distended, knees drawn up. Patient lies very still. Abdomen 
tense, extremely tender, especially hypogastrium. Uterus hard to 
find. Lochia often diminished, fetid. Lactation often ceases. 

Course of the Disease — Majority get well if the inflammation 
remains localized, also if the gonococcus is involved alone, and if it 
is due to trauma with mild infection. If the pain is very severe it is 
a good sign, as the process usually becomes localized (Fehling}. 
The general peritonitis so quickly benumbs the patients that they are 
not tender. Fever continues four or five days, but the patient may 
have an evening rise of temperature for a week or more. Later the 
symptoms of chronic pelvic peritonitis and those of adhesions come 
on. 

If suppuration occurs the patient becomes hectic and passes 
through the same course as in parametritis. The pulse gets better 
quickly if the process tends to localize, but if it tends to spread the 
pulse goes up, getting smaller and weaker. The pulse is therefore 
the most important index as to the severity of the disease. 

Differential diagnosis from Parametritis, — the peritoneal symp- 
toms, e. g., pulse, nausea, tympany, collapse, pain, etc. If the peri- 
tonitis becomes general, symptoms get worse. Pulse imperceptible, 
may be rapid. Temperature goes down, pulse goes up. Collapse, 
facies Hippocratica. Immense distension of the abdomen, involun- 



'NOTES ON OBSTETRICS—SENIOR CLASS. 463 

tary bowel movements and urination. Vomits green: — consciousness 
till near the last, however. 

Treatment of Parainetritis and Perimetritis — 
I. Rest, absolute. 
II. Opium, to quiet pain, procure rest and sleep. 

III. Ice-bag, Leiter's coils. See that they are well applied. 

IV. Local treatment at very beginning. Nothing later. If there 
is anything in the uterus it must be removed as early as possible. 

After peritonitis symptoms are present it is risky to tamper 
with the uterus. Some authors advise leaving it alone, at all hazards. 
\". Diet and support of patient — First 36 hours nothing but per- 
haps a little w^ater. As the symptoms subside, a full liquid stimulant 
diet is instituted. Tonics. 

SEPTICEMIA. 

This is what was formerly known as Puerperal Fever, — consid- 
ered an essential disease, peculiar to lying-in w^omen, contagious, 
like small-pox, due to the action of some external morbus, carried 
by the air, water, or soil. 

Semmelwxiss tried to impress on the profession that it was noth- 
ing but a wound infection — an opinion which is now held without 
question. 

Definition — Septicemia is an acute infectious disease, due to the 
entrance into the blood of microbes, usually the streptococcus pyo- 
genes, but sometimes of other cocci and bacteria, and their toxines, 
which produce a dissolution of the blood, degenerative changes in 
the organs, and the symptoms of a rapid intoxication. The toxins 
alone may be asorbed from a focus of infection and may. be suf- 
ficient to cause death. Septicemia may begin as such from an in- 
significant atrium of infection and may destroy life without marked 
local symptoms, the disease running its course in 24 to y2 hours, 
but usually there are local symptoms which indicate the source and 
the site from which the poisons are invading the blood. 

Septicemia may develop suddenly in the course of what seemed 
to be a mild endometritis or other local inflammatory process, due 
perhaps to improper treatment ; cr weakening of the resistance of the 
patient. 

Any of the local infections already considered may be the source 
of a general infection, e. g., a perineal tear may give rise to a viru- 
lent sepsis. It is often difficult to say how much of the severity 
of the disease is due to toxines absorbed from the infected pelvic 
structures, and how much from the invasion of the blood by germs. 

Symptoms — Sometimes begin during labor, or before the third 
day. Severe chill, acute rise of temperature, 104-105 — continuous 
fever with but slight morning remissions. Pulse immediately rises 



464 NOTES ON OBSTETRICS—SENIOR CLASS. 

in frequency, grows small, compressible, 140-160 even on the sec- 
ond day in severe cases. 

Respirations increased in frequency, shallow, with no lung com- 
plication, 40 to 60. per minute; due to early disintegration of the 
blood, with the loss of the oxygen carriers. 

Malaise, apprehension of a dangerous illness, even early the in- 
stinct of death impending, general prostration, patient seems to have 
been struck down, the change is so marked. Headache, early sleep- 
lessness (a very significant symptom if there are no other causes 
for it). May be slight delirium. 

Symptoms of peritonitis very soon begin and the facies Hip- 
pocratica shows the fatal termination is not distant. The lochia are 
usually putrid, the result of a gangrenous endometritis, though some- 
times the lochia are scant, the odor is not marked, being pungent to 
the nostril. The puerperal wounds become necrotic. Signs of peri- 
tonitis begin, and if the patient lives, become marked, and the picture 
becomes one of virulent peritonitis. The temperature goes down, 
the pulse higher, the tongue dry and fuliginous. The patient has a 
peculiar, fruity odor, sweet, sickening, may be very marked. After 
three or four days the patient feels easier, but the objective signs are 
worse. There is great tympany, the patient is cold, sometimes even 
the trunk, with a cold sweat, she is of a yellowish color, while the 
translucent parts, e. g., nose and ears are leaden gray. Conscious- 
ness is retained till a few hours before death which usually occurs 
in coma. If the patient lives long enough a pleuritis develops. Dis- 
ease lasts from 2 to 10 days. Is especially virulent if it begins dur- 
ing labor, when the course is usually short and violent, ''foudroyante." 
Eruptions on the skin occasionally occur, resembling scarlatina. 

Diagnosis of Sepsis — Really consists of a proper estimation of 
the severity of the attack (as from the milder forms), and this you 
must make early, as everything depends on it. 

1. General impression of a severe sickness — collapse. 

2. Pulse and temperature — chill. 

3. Local findings — uterus large and soft. Lochia fetid — pus. 

A soft uterus one of the first signs of infection. 
A hard uterus a good barrier to infection. 

4. Sleeplessness, — Delirium. 

5. History of case, e. g., placenta previa with severe operations, — 
midwives and doctors that are not clean. 

Prognosis — Usually fatal. Rarely get well. The earlier the 
symptoms appear the worse the prognosis. 
Pathologic Anatomy — 

1. Endometritis-gangrenosa, or diphtheroid, — the whole uterus 
being gangrenous — ichorous. The process often begins at the vulva 
and the whole genital tract is badly inflamed. 

2. Parametritis is usually present and lymphangitis, the lymph 



NOTES ON OBSTETRICS—SENIOR CLASS. 465 

vessels filled with thrombi. The connective tissue may be infiltrated, 
edematous, and this may spread with great rapidity. This cellulitis 
may spread so fast and far as to justify the name Virchow gave it — 
Erysipelas puerperalis malignum internum. 

3. The lymph vessels alone involved — full of lymph and some- 
times infiltrated with pus, — find them at the side of the uterus. The 
changes in the parametria may be simply a serous infectious edema, 
or necrosis may occur, — a real phlegmon. 

4. Pelvic peritonitis, then general peritonitis. 

5. If the patient lasts long enough — pleuritis and pericarditis. 

6. Gastritis submucosa, — gastritis and enteritis and colitis. 

7. General pathology of acute infectious disease. Swollen spleen, 
fatty degeneration and cloudy swellings of muscles, especially the 
heart, liver and kidneys. Bacteria involved — streptococcus pyogenes 
usually (Bumm). 

Treatment — If a case of septicemia develops from a paramentritis 
or vulvitis or endometritis, there is little to change in the treatment. 

If the case shows from the start that it is a sepsis — whatever you 
do must be done immediately. No waiting till to-morrow. If the 
infection has already gotten a foothold, as a parametritis or 
lymphangitis, it is not possible to abort it. If, however, it is simply 
a severe form of absorption fever, due may be to a clot, or a necrotic 
piece of placenta, the treatment has a better outlook. Therefore, in 
almost all cases where from the start you can recognize the gravity 
of the infection, a careful disinfection of the genital tract is at- 
tempted. 

1. Remove retained placenta, or membranes. Never use the 
curette, always the finger. Care and antisepsis. 

2. Disinfectant uterine injection, 1% lysol before and after. Bi- 
chloride is dangerous in puerperal cases, because the vagina is robbed 
of epithelium, and are usually dangerous in anemia and Bright's dis- 
ease. Do not use permanent uterine irrigation. Symptoms of peri- 
tonitis contra-indicate all local treatment. 

3. Give ergot and hydrastis. Ice-bag to uterus. 

4. For the peritonitis, opium, rest, ice. 

5. Alcohol and diet. 

6. Cool baths, when there is no peritonitis or parametritis ; cool 
packs to reduce fever. No coal tar antithermics. 

7. Extirpatio uteri. Doubtful utility. 

8. Opening posterior cul de sac and packing pelvis with iodoform 
gauze. . ' 

. PYEMIA. 

It means literally pus in the blood which is not really the case. 
It is the third of the fever processes I mentioned, and occurs sporad- 



466 NOTES ON OBSTETRICS—SENIOR CLASS. 

ically. In the epidemics of puerperal fever, pyemia sometimes oc- 
curs, while septicemia forms the majority of the cases. Pyemia was 
already defined as that condition in which there are discharged into 
the blood from a locus of infection, bits of clot or pus microbes which 
find lodgment in various parts of the body, producing abscesses 
there. 

In pyemia infection takes place through the veins, therefore it is 
more common after placenta previa, and after manual removal of 
the placenta. In septicemia the process is usually of the lymphatics. 

The germs involved are the usual pus germs, but there may be 
mixed infection, as in septicemia. The process is often designated 
metrophlebitis. Sometimes a case that begins as a septicemia, be- 
comes more chronic, running under the picture of a pyemia ; this, 
too, without localization of pus in the distant organs. 

Findings — These are uterine phlebitis and periphlebitis, puru- 
lent thrombi in the veins of the placental site, and the pampiniform 
plexus, which sometimes extend to the cava. Pieces sometimes lodge 
in the lungs, causing bronchopneumonia, or, if minute, pass through 
and get to the liver, spleen and kidneys, pleura, joints, serous mem- 
branes in general. Also the thyroid, the brain, the eye, resulting in 
panophthalmitis ; endocarditis. 

The occurrence of an embolus and infarction is usually shown by 
a chill, but not all chills indicate formation of embolus. 

Symptoms — Begins usually in the second week, unless the process 
sets in, in the course of a colpitis, endometritis or pelveo-peritonitis. 
The patient usually has not felt well. Has a high pulse and a little 
fever. Rigor, often severe, sometimes lasting an hour, which may 
be repeated ; as many as 70 rigors have been reported. These do not 
necessarily mean emboli. The severer forms of infection have few 
chills, and some cases occur without chills at all. 

Fever rises directly and quickly, perhaps to 106 degrees F. After 
this a sweat occurs and the patient sinks into a collapse, tempera- 
ture 95° F. Temperature is now irregular, around the normal, till 
another chill and fever occur. The pulse goes with the fever, unless 
an embolus occurs in a vital organ. Between attacks, unless they 
are frequent, the patient feels well. No euphoria like in sepsis. The 
fever presents a jagged curve with or without the infarcts. 

Symptoms of infarcts are — 

a. Lungs. Cough, stitch in side, bloody, sometimes purulent, 
expectoration, dyspnea, pleurisy, or even, rarely, dullness and signs 
of pneumonia. 

b. Subcutaneous connective tissue. Anywhere, but especially 
the thighs. Pain, redness, swelling, fluctuation. This abscess may 
"localize" the infection, and the case recover at once. Has been imi- 
tated in treatment by injecting turpentine. 

c. Joints. The usual signs of acute arthritis. The whole joint. 



NOTES ON OBSTETRICS—SENIOR CLASS. 467 

May be disorganized and permanent anchylosis result. Knee most 
common but no joint exempt. 

d. Panophthalmitis. Disorganization of the eye-ball. Thyroiditis, 
metastases in the brain, etc., give the symptoms characteristic of 
these localizations. 

The thrombosis of the pampiniform plexus extends sometimes to 
the vena cruralis, with occlusions of same and resulting edema of the 
thigh and leg. This is one form of phlegmasia alba dolens. 

The course of the disease is protracted, and the patient may ex- 
pect a long invaUdism, extending over months or even years. 

Blood — The blood changes. Bacteria are sometimes found in the 
blood. If they should be found during a septicemia the case is usual- 
ly fatal. Leucocytosis. Neutrophilia present. Differentiated thus 
from typhoid, where there is leucopenia. No Widal reaction in 
sepsis. 

Diagnosis — The diagnosis is usually easy, from the course of 
chills, fever and emboli. Abscess in the pelvis presents similar symp- 
toms. Examination reveals no mass in pelvis. Rarely feel thickened 
broad ligaments. 

Prognosis — Better than septicemia. The more chronic the dis- 
ease, the better the prognosis as to life, the worse as to health (arthri- 
tis, many abscesses, hectic, amyloid). 

The shorter the disease the worse the prognosis as to life usually, 
and the better the prognosis as to general health later. Give guarded 
opinion because the cases at no time are out of danger. The severity 
of the case depends on the virulence of the germ, the resisting power 
of the patient and the localization of the emboli, i. e., the physiologic 
dignity of the structure involved, e. g., if in the skin, joints, even the 
pleura, good. If in the brain, lungs, heart, liver, kidneys, bad. Much 
depends on the possibility to drain the abscess. 

Treatment — Treat the chill — heat, hot drinks, stimulation. For 
the fever, do nothing, — it goes down soon. 

Rest to prevent thrombi breaking loose. Treat metastases on 
purely surgical principles. Nourishment important, as the disease is 
protracted. In 1894 Sippel (c. f. g. 1894, No. 28, and 1902, No. 50) 
advised extirpation of uterus and ligation and removal of thrombotic 
veins. Trendelburg resected hypogastrium and spermatic plexuses. 
Narcotics for pain. Must use morphine in bad cases. No spe- 
cific treatment. The serum of Marmorek of doubtful utility. Pre- 
vent bedsores, which are very prone to form. Salt solution by hypo- 
dermoclysis good, also by prolonged rectal irrigation. Nuclein of 
doubtful value, ditto Crede ointment. 

SEPTIC ENDOCARDITIS. 

Usually compHcates a septicemia but may occur after a mild 
local infection, or even without demonstrable local disease. Due to 



468 NOTES ON OBSTETRICS— SENIOR CLASS. 

infection of the valves, oftenest of the left heart with ulceration of 
same, and is marked by the presence of miliary embolic abscesses 
in the brain, liver, kidneys, etc. An endocardium that is already 
diseased is more prone to infection. Chlorosis seems to favor 
it, too. 

Symptoms — Severe rigor, high and continuous fever, very rapid 
pulse, cerebral symptoms, muttering delirium, stupor, or even acute 
delirious mania. Sometimes symptoms of meningitis. Retinal 
hemorrhages in 8o>4 (Litten). Diarrhea. Hemorrhage under skin, 
scarlatiniform eruptions, or blisters. Disease lasts lo to 28 days. 
Often appears like typhoid. Has roseola, enlarged spleen and 
tongue. 

Heart -findings usually equivocal. Sometimes sudden death. 

Diagnosis — This is not easy. Absence of local cause for the 
high fever and rapid pulse. Severe sickness, marked nervous symp- 
toms, retinal hemorrhages, repeated chills without determinable em- 
boli. 

Prognosis — Is bad. 

Treatment — Symptomatic. 

PHLEGMASIA ALBA DOLENS. 

This term is rather loosely used to express three different path- 
ological states : 

1. A pelvic cellulitis which extends to the connective tissue un- 
der Poupart's ligament, and then involves the upper third of the 
thigh, — the real phlegmasia alba dolens. 

2. A thrombosis of the femoral, or iliac vein, which causes stasis 
and edema of the leg and thigh — simply mechanical. 

3. A phlebitis occurs, either from a neighboring cellulitis, or 
from extension from the inflamed veins of the uterus, through the 
pampiniform plexus. 

I. The first form, to which the name properly belongs, is 
only the extension of a pelvic cellulitis up and out of 
the pelvis and down the thigh. The sw^elling first 
appears under Poupart's ligament, and sometimes lim- 
ited to the upper third of the thigh, 
n. The causes of primary thrombosis of the crural and 
femoral veins are, stasis of the blood in the legs, which 
may cause thrombosis even during pregnancy; the 
muscular rest after labor ; the slow circulation in the 
distended veins ; the almost hyperinotic condition of 
the blood (especially after large hemorrhages) ; press- 
ure on the veins by pelvic exudates ; marasmus after 
long febrile diseases, called marantic thrombosis. 



NOTES ON OBSTETRICS—SENIOR CLASS. 4G1J 

III. Phlebitis — This may come from extension of the in- 
flammation of the veins of the uterus along the veins, 
or from a neighboring celluHtis by extension of the 
inflammation through the veins, e. g., the patient has 
a crural cellulitis, the vein becomes inflamed and there- 
fore thrombotic. This may be reversed, sometimes a 
thrombo-phlebitis leads to a cellulitis, or a sirnple 
thrombosis becomes infected and inflammation re- 
sults. Sometimes emboli are detached from the veins 
and lodge in the heart and lungs, which may be fatal. 
If infected they produce the clinical picture of py- 
emia. 
Symptoms — The symptoms of crural cellulitis are those of a 
primary cellulitis (parametritis), plus those of cellulitis of the upper 
third of the thigh. 

Sometimes the intra-pelvic symptoms are mild and, therefore, 
overlooked. Patient has fever, high pulse, pain in the groin and 
thigh. The leg 'cannot be moved. The groin becomes tender, swol- 
len ; sometimes red, but usually whitish, edematous ; sometimes there 
are blisters. The leg is hard, and does not pit easily but the pitting 
stays longer than with simple edema. The swelling may be limited 
to the upper third or half of the thigh, but if the veins are involved 
and thrombosis occurs, the foot begins to swell and soon the whole 
limb is large, white and puffy ; therefore, the old appellation "milk 
leg." It was thought to be a milk metastasis. In lo to 14 days the 
inflammation usually subsides and the edema begins to go down. 
But it may be chronic and the patient has to wear a rubber stocking, 
or it reappears when the patient is on her feet a good deal. 

In the mechanical form of thrombosis there is no fever. The 
swelling first appears on the foot, the pulse is rapid (without fever), 
Mahler's sign, the pain is not so marked, the thrombosed vein can 
often be felt, as a hard, tender, knottv cord, and the patient does not 
feel ill. 

In the thrombo-phlebitic form we have the same symptoms and 
findings as in the last, plus the symptoms of fever, of infection. 

Prognosis — Good, but somietimes an abscess forms which may 
burrow all through the thigh or even be fatal. May be bilateral, 
which clouds the prognosis. 

Treatment — Rest for the leg in a slightly elevated position. No 
massage, except late in the case to favor resorption of chronic edema. 
No movement, especially if there is thrombosis, for several weeks, 
till the clots are firmly organized. Danger of embolism. Locally, in 
the cellulitic variety, wet boracic dressing for several days, then sim- 
ple protection. Watch carefully for bed-sores. Otherwise symp- 
tomatic treatment. 



470 NOTES ON OBSTETRICS—SENIOR CLASS. 

OTHER INFECTIONS. 

There are other puerperal infections, e. g., erysipelas, beginning 
in the genitals, true diphtheria of the genital tract, tetanus, which 
seems to be commoner after abortions, tuberculosis and gonorrhea. 
This last is being more and more recognized as a cause for puerperal 
infection. It occurs later in the puerperium, usually after the third 
week, but may occur earlier. It causes endometritis, salpingitis, 
ovaritis, leading to pyosalpinx and ovarian abscess or even pelvic 
peritonitis. It may or may not be accompanied by the pus germ, 
and is dangerous also alone. 

Principles of Treatment — Before leaving the subject let us sum 
up the principles of the treatment of puerperal infection. 

Having determined that the fever comes from the genitalia, you 
must settle the following questions : ( i ) Is the fever from some- 
thing retained and decomposing in the uterus or vagina, e. g., pieces 
of placenta, blood clot, lochiometra, lochiocolpos ? (2) Is the infec- 
tion still in the genital tract, or is it already beyond the surface, or 
has it indeed become general? (3) What anatomical structure is 
mostly involved, or does the infection line the whole parturient canal ? 
(4) What is the nature of the infection, pus germs, saprophytes, 
bacterium coli communis, diphtheria, etc.? 

1. If one is convinced that there is something in the uterus caus- 
ing serious symptoms, especially fever with high pulse, remove it 
gently with the fingers, preceding and following with an antiseptic 
douche. 

2. When the parturient canal is empty leave it alone, give ergot ; 
opium for the pain,, sleep, peritonitis ; support the patient's strength in 
every way. 

3. When the infectious process has become localized in the uterus 
or adnexae, or an abscess forms which continues as a focus from 
which systemic infection proceeds, surgical interference is indi- 
cated. 

The treatment of puerperal infections has developed another 
and important aspect in the last few years, due to the introduction 
of serum therapeutics. We have now an antistreptococcus serum, 
and the latest is an antistaphylococcus serum. While a large propor- 
tion of the puerperal fevers are due to the streptococcus, not all 
are, and, therefore, the routine use of this serum is irrational. The 
exact nature of the cause being determined, the serum may be ex- 
hiibted. The reports are not encouraging. It is safe and, therefore, 
frequently used. 

In cases of puerperal tetanus the anti-tetanus serum should be 
used under the same conditions as govern its exhibition in general 
surgery. 

In diphtheria^ aifecting the puerpera in any part, the anti- 



NOTES ON OBSTETRICS—SENIOR CLASS. 471 

toxin should be exhibited and prophylactic injections also. One 
must not confuse diphtheroid patches, which may occur in any in- 
fection of the genitals, with true diphtheritic exudates. 

There are several agents which are strong auxiliaries. Of these, 
saline infusions may be given first place. A quart of 7-10% salt 
solution injected under the breast each day, and especially if there 
is collapse, may save an otherwise hopeless case. Bosc, Claisse, 
Pozzi, have drawn particular attention to this line of treatment. J. 
G. Clark, of Baltimore, records a very successful result in a severe 
puerperal fever. Rectal irrigation with salt solution continued for 
I or 2 hours may help, too. Runge recommends large doses of alco- 
hol combined with cool baths. The latter ought to be supplanted by 
cool sponging to avoid the exertion and disturbance of the pa- 
tient. Regarding alcohol, opinions differ. I would not put my faith 
in it, though I do not believe it harmed those cases to which it was 
given. Give no more than gii daily. Crede ointment is useless. 

Quinine is not a specific in puerperal infections. Its value in 
fevered conditions is generally recognized, and this is due to its 
powers as a general tonic. 

In conclusion, reference may be made to a class of cases where 
on the third or fourth day the patient is seized with symptoms re- 
sembling puerperal infection, but which are due to constipation, and 
which subside on free movement of the bowels. These cases are 
not fully understood ; they may be serious, and if an infection of the 
parturient canal with the bacterium coli communis takes place, may 
be fatal. The French call them pseudoinfections. Their prevention 
requires attention to the bowels before labor and a laxative in the 
first two days after confinement. 

THE BREASTS. 

The most common trouble with the breasts is the lymphatic and 
glandular engorgement that occurs, especially in primiparae, when 
the milk comes in. The breast is large, hot, tense, painful, shiny, 
the lobules enlarged, the nipple flattened ; there is often a detached 
lobule in the axilla which also is enlarged and painful, so that the 
patient cannot bring her arms to the sides. The veins are distended. 
There is no fever. The skin is edematous and pits on pressure, the 
child cannot grasp the nipple and the patient often becomes highly 
nervous from the condition. This swelling is not due to the presence 
of milk, but tO' lymphatic and vascular engorgement. There is a very 
little milk already formed in the breasts at the beginning of nursing, 
but most of it is made during the time of the nursing by the stimula- 
tion of the gland. Thus, there is no reason to "massage the milk 
out." The rubbing stimulates the breasts to make milk and the 
engorgement is, therefore, increased. 



472 NOTES ON OBSTETRICS—SENIOR CLASS. 

Later, in the lactation period, and in multiparae, at the times of 
the nursings, the milk begins to form, from habit, and the milk in 
certain quantities runs from the breast. But this is not the rule, 
and therefore is not the guide to practice. 

Treatment — Give a saline laxative, reduce the amount of fluids 
taken, bind the breasts tightly with an evenly applied binder. Have 
the nurse (or do it yourself), by even pressure with the outspread 
hands, press the breasts against the chest wall so as to reduce the 
tumefaction. This is not a massage, but just an evenly distributed 
pressure, pressing the lymph out of the breasts just as we would 
keep pressure on a contusion to reduce the swelling. Then an ice- 
bag may be applied to each breast. Some women prefer warmth, 
so in these cases great good will be accomplished with a wet boric 
dressing (2%) covered with oil silk or rubber tissue and held with 
a firm binder. Reduce the frequency of the nursings, do not use 
the breast pump, and do not massage. If massage is practiced, the 
rubbing should be toward the periphery of the gland, not toward the 
nipple. See "Obstetrics for Nurses," page 275. 

The Nipples — These are often a source of trouble, and though 
apparently insignificant, may lead to very serious results, namely, 
discontinuance of the nursing and abscess of the breast, even death 
from septicemia. Therefore, pay close attention to the nipples. They 
may be retracted, mulberry shape, bifid, polypoid, etc., all of which 
favor the formation of cracks and fissures. These lead to infection, 
or they render nursing so painful that it must be given up, which 
is a serious matter for the baby. Sometimes, without any apparent 
cause, the nursing is too painful, so that it has to be given up. These 
cases usually occur in neurotic individuals, or where there is not 
enough milk. The nurse should watch the nipples carefully. If 
there is pain in nursing, inspect the nipple with a magnifying glass. 
At the first appearance of a blister or a crack, redouble antiseptic 
precautions. Put on a Wansbrough's lead nipple shield and use a 
glass nipple shield for nursing. If this treatment is not quickly 
successful, touch the crack with a 2% AgN03 sol. and let dr}^ Then 
lead shields again, Succedanea, are 4% boric acid in glycerine, tr. 
benzoin comp., — all allowed to dry in well. Rarely 2^ % AgN03 i'^ 
collodion may be used. Belladonna ointment and a host of other 
remedies fail and succeed in isolated cases. Infection of the breast 
not seldom follows a crack or blister, therefore, careful. 

Mastitis — There are several forms. A sm^all abscess forms in the 
areola, due to infection of a tubercle of Montgomery. A c^lulitis 
starts from the nipple and spreads under the skin, like a cellulitis 
anywhere. Important as to diagnosis, the treatment is like that of 
cellulitis in general. 

The most important cases of mastitis are those — ist, where the 
infection proceeds down the milk tubules, producing a paren- 



NOTES ON OBSTETRICS—SENIOR CLASS. 473 

chymatous inflammation of the gland; 2nd, where the infection trav- 
els alongside the tubules to the connective tissue around the lobules 
producing a perilobular mastitis ; this can seldom be distinguished 
clinically from the parenchymatous ; 3rd, where the infection goes 
deeply but passes the gland proper and there is a retro-mammary 
cellulitis, with pus formation in the deep connective tissue. 

Cause — Infection, which may be brought in from the outside; 
from the woman herself, lochia, etc. ; from the baby, navel, ophthal- 
mia, mouth, thrush ; from the gland itself. There are staphylococci 
in many breasts and sometimes streptococci in the milk ducts, wait- 
ing for favorable conditions to enter the lymph spaces. Such favor- 
able conditions are cracks, fissures, bruises 'from injury, either acci- 
dental, or from massage, pumping the breasts, prolonged and forced 
efforts at nursing when there is no secretory activity in the gland. 
It is doubtful if so-called milk stasis, or ''caking" of the breasts itself, 
will cause mastitis or even favor infection, from the germs present, 
unless the breast be injured by massage, or attempts to force milk 
out of the congested lobe. 

Mastitis may occur at any time during pregnancy and the puer- 
perium, also, but rarely, in the non-puerperal state. Most often in 
the second week post partum. Primiparae oftener than multiparae. 
One attack predisposes to another in the next lactation. Begins with 
pain in the breast, especially during the nursing. One lobe is tender, 
hard, swollen, sometimes a little reddened ; the secretion of milk in 
that breast is less, it sometimes ''cakes," which gives rise to the 
thought that the caking causes the mastitis, when really the infection 
is the cause of the caking. 

There is a slight feverishness, and accelerated pulse. In the 
presence of these symptoms, especially if there is a crack you may 
diagnose an incipient mastitis, and treatment is now efficacious in 
aborting it. After a few days of these symptoms the patient has a 
chill, more or less severe, a sudden rise in temperature and pulse, 
sometimes 104° F. and 120 to the minute. All the symptoms of high 
fever. Pain in the breast which may be at a small spot or all over the 
breast. Swelling of the lobe, tenderness, later redness. 

If nothing is done the gland breaks dow^n, the skin becomes ad- 
herent to it and an abscess forms and breaks, more or less of the 
whole breast being disorganized. The fever is high till pus forms, 
then irregular till it is evacuated, then normal temperature unless 
drainage is bad, or the other breast begins to inflame. If the gland 
structure alone is involved may be able to press out pus from the 
nipple, but this must be done gently. Rare. 

If a retro-mammary abscess forms, the constitutional symptoms 
are severe and threatening, general sepsis may occur and the condi- 
tion should be early recognized and treatment radical. 

Prognosis — With proper treatment of a mastitis, i. e.. if it is 



474 NOTES ON OBSTETRICS— SENIOR CLASS. 

recognized early, nearly every case can be aborted. If not, then many 
cases will go on to abscess. The breast may be riddled with abscesses 
and suppuration go on for many months till the patient is much 
pulled down. With proper treatment this can also be prevented. 

Diagnosis — Usually easy, but with severe constitutional symptoms 
and slightly marked local findings the idea of a late puerperal in- 
fection may corne up. Sometimes the two may go together. 

Treatment — If you see a mastitis threatening, or if the patient 
has had the chill with fever : 

1. Take baby from both breasts absolutely. 

2. Give the patient a bottle of liq. Magnesii citratis, and repeat in 
six hours, if necessary. Reduce liquids in diet. 

3. Wash breasts with i-iooo Hg CI2, put on a tight breast binder. 

4. Put two ice-bags on each breast, and keep the breasts cold till 
24 hours after the temperature is normal. 

In a few hours the temperature begins to fall and in 16 hours 
may be normal. Swelling goes down. A Httle tenderness may re- 
main. If, after 48 hours of ice, there is no effect you may count 
on suppuration resulting. If the temperature goes down to normal 
for 24 hours, remove the ice-bags, put on a binder. The baby may 
nurse after expressing a little milk from the nipples. Begin tentative- 
ly, watching pulse and temperature. When suppuration is inevitable, 
remove the ice and put on a wet boric dressing. Surgical treatment 
now in order ; remove the lobe infected. This is the best treatment, 
as it prevents prolonged suppuration. If impossible to do this, 
make a long, radiating incision into the infected lobe and curette 
out all the diseased gland thoroughly, breaking up all the various 
cavities into one, then pack with gauze and let it heal up from the 
bottom. Be thorough as the healing will then be shorter. The im- 
portance of making radial incisions to avoid the milk ducts was 
known to the Hindoos 160 years A. D. See Ayur Veda of Susruta. 
Kossman All. Tyre, page 10. 

Operate as soon as you know there is pus. 

Patient must give up nursing entirely as the stimulation keeps 
up secretion in the sick breast ; further, the child may get sepsis. 
Get the patient up as soon as possible and out of doors, to build up 
her strength. 

Agalactia — Scantiness of milk is not uncommon, also the milk 
not agreeing with the child. In some cases it really acts like an irri- 
tant poison, and may lead to digestive disorders resulting fatally. 

The causes of a scanty milk supply are, general ill-health, mal- 
development of the breasts, either congenital, from abscess of the 
breast, or from compression by vicious dressing, insufficient stimula- 
tion, i. e., half-hearted attempt at lactation, nervous influences (rare 
and dubious). 

Treatment — Protect the breast from girlhood by proper hygiene. 



NOTES ON OBSTETRICS—SENIOR CLASS. 475 

mental and physical. During pregnancy, allow free development of 
the glands. Don't give up nursing too soon, perhaps the patient may 
supply half the baby's food. Of the various stimulants to the milk 
secretion few are of real value. 

Massage t. i. d., gently, so as not to injure the breast and thus 
cause abscess. When patient can do so, cool baths with friction of 
the body and light friction on the breasts. Let a strong baby nurse 
frequently. 

Of medicines there are none of service. 

Food — Liquids of all kinds, especially milk. Oatmeal gruel, 
barley gruel, chocolate, oyster stew, all useful. 

Malt of no use. Milk gets fatty and dries up, while the patient 
also puts on fat. 

If the patient finally succeeds in giving milk, the supply is usual- 
ly insufficient and sometimes not good, so that all methods of forcing 
the secretion are unsatisfactory. Should she begin to complain of 
pain in the breasts with drawing pains running around to the shoul- 
der blades, this is an indication that lactation is a drain on her 
system and it should be discontinued. 



